Guiding you on the road ahead

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2 Guiding you on the road ahead So, what s changing in the landscape of healthcare coverage? Well, some of the most significant provisions of the Affordable Care Act go into effect beginning in And that means lots of changes coming your way. But you don t need to worry, with Blue Shield we ll not only help you navigate your way to a great plan, we ll provide plain, simple explanations so you can be sure that you ve made an excellent choice for you and your family. In this guide, you ll find our new high-quality, affordable plans for individuals and families. Not only do they comply with the Affordable Care Act, they re also simple to understand, because our goal is to give you clear and helpful directions. Before embarking on any new journey, there are bound to be a few questions. So here s a helpful little Q&A before we get on our way. Why should I buy a health plan? Starting in 2014, having health insurance is the law. So if you re not getting coverage through your place of work or through a government-sponsored program, then you ll have to buy an individual or family plan to avoid a tax penalty. Plus, having health coverage is an important way to help you get care when you need it, and you can feel more secure that you will avoid unmanageable expenses. 0 3

3 What if I have a preexisting condition? Will that be a problem? Starting in 2014, no one can be denied coverage for preexisting conditions. So even if you have a preexisting condition, you ll get the same access to health coverage as everyone else. It s a truly remarkable part of the Affordable Care Act, since it establishes an unprecedented guarantee of coverage to everyone, greatly reducing the chance that an individual or family could be left with excessive medical bills. And even if you have a health condition, you won t I m not sure I can afford healthcare coverage. What can I do? You may be eligible for federal subsidies in the form of premium/dues assistance (also known as tax credits) to help pay for your health coverage. Depending on your income level, you may also qualify for a plan which reduces the costs when you use services. We can help you figure out whether you qualify, and, if so, show you how to get assistance through Covered California, a new statewide health insurance marketplace. How do I buy a plan from Blue Shield? Blue Shield offers medical, dental, vision, and term life insurance* plans, as well as a convenient dental + vision* package. Contact your authorized Blue Shield broker for assistance. * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). It s true. The Affordable Care Act is transforming healthcare coverage and Blue Shield will make sure you are ready for this change. We ll make sure to get you the information you need to find a Blue Shield plan that s right for you. be charged a higher rate because of it. 0 1

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5 Why you should ride with us What drives us? First and foremost, our focus is on quality healthcare coverage at an affordable price. But a close second is a little something we like to call keeping it simple. Shopping for a health plan doesn t have to be complicated. That s why we ve mapped out our plans to be simple to understand and compare, providing a clear path to finding the coverage you need. If you re shopping around. We re proud to say that our plans have been selected by Covered California across the state, so you re sure to find high-quality and affordable Blue Shield coverage options available to you. You ll find that our rates are among the lowest available whether you buy them from Blue Shield through your broker or through the new Covered California healthcare exchange. Our networks include many excellent doctors and hospitals. And our members seem to like us: They rate us 4 out of 5 stars* in overall customer satisfaction. * Based on data from Blue Shield Ratings & Reviews data as of August 21,

6 You re almost ready to roll We re on an affordability mission. Blue Shield of California is a not-for-profit company. Our mission is to ensure all Californians have access to affordable health coverage. We pledge to limit our annual net income to 2% of revenue* and if we earn more than 2%, we ll return the difference to our customers and the community. We ve developed whole new provider networks that are working with Blue Shield to lower costs. These new networks make it possible to provide you access to quality healthcare coverage with a lower impact on your pocketbook. *Subject to the board of directors approval. F E 0 4

7 Find a model you can afford. From the basic to the fully loaded, we re proud to offer plans designed to fit your varying budgets and needs. And all of our plan options are compliant with the Affordable Care Act, and align with the four metal levels of coverage established by the law Ultimate (Platinum), Preferred (Gold), Enhanced (Silver), and Basic (Bronze). We also offer a Get Covered (Catastrophic) plan. But you can think of them as our brand-new models. Each varies according to price and amount of coverage, allowing you to find the premium/dues, copay, and deductible combination that s right for you. Plus, all our plans provide coverage for all the essential health benefits: Ambulatory patient services Emergency services Hospitalization Maternity and newborn care Mental health and substance use disorder services Prescription drugs Rehabilitative and habilitative services Laboratory services Preventive and wellness services Pediatric services, including dental and vision care Regularly scheduled maintenance. To help keep you and your family in top shape, all of our plans cover preventive care services at no additional cost, even before you meet a plan deductible. Good prevention starts early and continues throughout your entire life. Even if you feel fine, going to the doctor for checkups is part of living a healthy lifestyle. These covered screenings check for problems early, before you feel signs of sickness, and give you more care choices with better results. Healthcare coverage that s loaded with options. At Blue Shield, we can be your one-stop shop for the entire healthcare coverage package. This means medical, dental, vision, and life insurance* coverage all to save time and money, and all in one place. *Life insurance is underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). care

8 Del Norte Siskiyou Modoc Humboldt Trinity Shasta Lassen Tehama Plumas Mendocino Glenn Colusa Lake Sutter Butte Yuba Nevada Sierra Placer Sonoma San Francisco San Mateo Marin Santa Cruz Yolo Napa Santa Clara Sacramento Solano San Contra Joaquin Costa Alameda Stanislaus El Dorado Calaveras Merced Amador Alpine Tuolumne Mariposa Madera Mono San Benito Fresno Inyo Monterey Kings Tulare San Luis Obispo Kern San Bernadino Santa Barbara Ventura Los Angeles Orange Riverside PPO EPO No Blue Shield covered California health plans are available for purchase in this county. San Diego Imperial 0 6

9 We ve got California covered PPO plans Our PPO plan provides access to our Exclusive PPO Network of participating doctors, specialists, and hospitals. Members have the freedom to see any doctor in this network without a referral. You even have the option to receive care from non-participating providers, if you re willing to pay more out of pocket. If you don t live in one of these counties, you may be able to purchase one of our EPO plans available in most other areas of California. Visit blueshieldca.com/ findaplan or contact your authorized Blue Shield broker for more information

10 A checklist before we get going When it comes to healthcare coverage, everyone s needs are unique. That s why our goal is to provide you with the information you need to choose a Blue Shield plan. So take a look and find the one that will perform best for you. We can even help you find out if you are eligible for assistance through Covered California and, if so, we will assist you with your application.

11 Help paying for coverage Under the Affordable Care Act, eligible individuals and families can qualify for financial assistance to help with monthly rates and out-of-pocket healthcare expenses to ensure that everyone has easier access to quality healthcare coverage that s affordable for them. Covered California offers financial assistance depending on your income and family size. Take a few minutes to answer a few questions to determine whether you may be eligible for assistance. Are you eligible for premium assistance? 1 Does your employer offer health coverage that meets the minimum value standard?* * You may be eligible if the employer plan does not cover at least 60% of covered benefits on average or if the employee share of the premium exceeds 9.5% of the employee s income. 2 Do you receive Medicaid or Medicare? 3 Does your family make more than the annual income below? Family Size Yearly Income 1 $45,960 2 $62,040 3 $78,120 4 $94,200 5 $110,280 6 $126,360 If you answered NO to ALL of these questions, you may qualify for premium assistance through Covered California (in the form of tax credits), which lowers your monthly rates, and you may qualify to purchase a plan with reduced cost-sharing amounts. Even if you think your income is somewhat higher than these amounts, you may still qualify. TM Your authorized Blue Shield broker can help you determine if you re eligible and, if so, can help you submit your application through Covered California. Call your broker to get free and personalized assistance in helping you better understand your options

12 Let s check the specs Ultimate plan (Platinum level): 90% Blue Shield Ultimate PPO Platinum Level Blue Shield pays, on average, 90% of covered medical expenses. Our Ultimate plan offers you the lowest out-of-pocket costs for medical services. There are no deductibles, so we start paying for covered benefits right from the start. By paying higher monthly premiums/dues, you ll usually pay less when accessing care for medical services such as doctor visits, prescription drugs, and hospitalization. 80% Blue Shield Preferred PPO Gold Level Blue Shield pays, on average, 80% of covered medical expenses. Preferred plan (Gold level): Our Preferred plan offers good coverage with manageable out-of-pocket costs, so it s easier to predict additional expenses. There are no deductibles, so Blue Shield starts paying for all covered benefits immediately, including popular benefits such as doctor visits, prescription drugs, and urgent care. 70% Blue Shield Enhanced PPO Silver Level Blue Shield pays, on average, 70% of covered medical expenses. Enhanced plan (Silver level): Our Enhanced plan offers a good balance between your premium and your out-of-pocket costs. You ll receive benefits like doctor visits and generic drugs prior to meeting an annual deductible. Other covered medical services, such as hospitalization, are covered after you meet the annual medical deductible. If your income is below 250 percent of the federal poverty level (about $60,000 for a family of four), you may be eligible to save on costs with one of our three Enhanced cost-sharing reduction plans: Enhanced PPO 150 Subsidy Enhanced PPO 200 Subsidy Enhanced PPO 250 Subsidy Enhanced cost-sharing reduction plans purchased through Covered California offer lower copayments, deductibles, and out-of-pocket maximums than standard plan designs, so you'll pay less when accessing services from participating providers. Blue Shield or your broker can help you determine if you're eligible and, if so, can help you with submitting your application to Covered California.

13 60% Blue Shield Basic PPO Bronze Level Blue Shield pays, on average, 60% of covered medical expenses. Basic plan (Bronze level): Our Basic plan is designed for people who want affordable coverage with low monthly rates in exchange for a higher deductible for protection in the event of a serious medical emergency. Benefits like preventive care and three doctor visits are available for a fixed copayment before meeting the deductible. 60% Blue Shield Basic PPO for HSA Bronze Level Blue Shield pays, on average, 60% of covered medical expenses. Basic for HSA plan (Bronze level): If you re looking for a plan with lower monthly rates and a way to better manage your healthcare coverage spending, look to our Basic Plan for high-deductible health plans that are Health Savings Account* eligible. With an HSA, you can prepare for future medical costs by contributing pre-tax money to your own HSA for healthcare-related expenses. You ll even enjoy preventive care visits before meeting the deductible. * Although most individuals who enroll in an HSA-compatible health plan are eligible to open an HSA, you should consult with a financial adviser to determine if an HSA/ HDHP is a good financial fit for you. Blue Shield does not offer tax advice for HSAs. HSAs are offered through financial institutions. For more information about HSAs, eligibility, and the law s current provisions, you should ask your financial or tax adviser. 60% Blue Shield Get Covered PPO Blue Shield pays, on average, 60% of covered medical expenses. Catastrophic Get Covered plan (Catastrophic): This plan is designed specifically for people under age 30, or those age 30 and above who can provide a certification that they are without affordable coverage or are experiencing financial hardship, and are simply looking for a low-cost option. It carries a high deductible. Most services are subject to the medical deductible; however, important benefits like preventive care and three doctor visits are available, if necessary, for no additional cost before meeting the deductible. Native American plans: In addition to the plans described in this guide, we also offer the following plans for Native Americans: Ultimate PPO Native American, Preferred PPO Native American, Enhanced PPO Native American, Basic PPO Native American, Basic PPO for HSA Native American, and Native American PPO 300 Subsidy. Contact your broker or Blue Shield for additional information on these plans. Visit blueshieldca.com for more information. 1 1

14 Comparing Blue Shield plans When comparing plans, it may be helpful to consider the balance of value and coverage. Here s a handy chart to help you compare our health plans: PLAN LEVEL ULTIMATE PLATINUM PREFERRED GOLD ENHANCED SILVER BASIC BRONZE BASIC FOR HSA BRONZE GET COVERED MINIMUM COVERAGE Blue Shield pays on average 90% 80% 70% 60% 60% 60% No medical deductibles Highest medical deductibles Lowest out-of-pocket cost when using medical services Most expensive when using medical services Brand drugs without deductible Cost-sharing reduction plan options for eligible individuals HSA-eligible Designed mainly for major or unexpected illness Lowest monthly rates Moderate deductible amount Good balance between monthly rate and out-of-pocket costs 1 2

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16 A side-by-side comparison ULTIMATE PLAN (PLATINUM) PREFERRED PLAN (GOLD) ENHANCED PLAN (SILVER) ENHANCED 150 SUBSIDY* PLAN (SILVER) Benefits 1 With participating providers, members pay 1 : Office visit primary care doctor $20 $30 $45 $3 Office visit specialist doctor $40 $50 $65 $5 Urgent care visit $40 $60 $90 $6 Preventive health benefits $0 $0 $0 $0 Inpatient hospitalization 10% 20% 20% 10% Outpatient surgery 10% 20% 20% 10% Lab $20 $30 $45 $3 X-ray $40 $50 $65 $5 Emergency room services not resulting in admission $150 $250 $250 $25 Maternity 10% 20% 20% 10% Generic drugs $5 $19 $19 $3 Preferred brand drugs $15 $50 $50 $5 Non-preferred brand drugs $25 $70 $70 $10 Chiropractic Not covered Not covered Not covered Not covered Acupuncture (from a licensed acupuncturist) $20 $30 $45 $3 Pediatric eye exam $0 $0 $0 $0 Pediatric eyeglasses $0 $0 $0 $0 Calendar-year medical deductible 2 $0 $0 $2,000 per individual / $4,000 per family $0 Calendar-year out-of-pocket maximum (includes deductible) $4,000 per individual / $8,000 per family $6,350 per individual / $12,700 per family $6,350 per individual / $12,700 per family $2,250 per individual / $4,500 per family Calendar-year brand drug deductible $0 $0 $250 per individual / $500 per family $0 = Benefit is available prior to meeting any deductible = Benefit is subject to a deductible This chart is an overview of benefits. For additional benefit information, cost for services, waiting periods, and exclusions and limitations, please see the Benefit Summary Guide and Important Legal Information booklets. Some benefits are subject to a deductible. You are responsible for all charges up to the allowable amount until the deductible is met. At that point, you will be responsible for the copayment or coinsurance for covered services as noted in the chart. In addition to the plans described in this guide, the following plans are also offered through Covered California: Platinum PPO Native American, Preferred PPO Native American, Enhanced PPO Native American, Basic PPO Native American, Basic PPO for HSA Native American, and Native American PPO 300 Subsidy. Please refer to blueshieldca.com for details. 1 4

17 ENHANCED 200 SUBSIDY* PLAN (SILVER) ENHANCED 250 SUBSIDY* PLAN (SILVER) BASIC PLAN (BRONZE) BASIC FOR HSA PLAN (BRONZE) GET COVERED PLAN (CATASTROPHIC) With participating providers, members pay 1 : $15 $40 $60 for first 3 visits per calendar year prior to deductible, then $60 after deductible 3 40% $0 for first 3 visits per calendar year prior to deductible, then $0 after deductible 3 $20 $50 $70 40% 0% $30 $80 $120 for first 3 visits per calendar year prior to deductible, then $120 after deductible 3 40% $0 for first 3 visits per calendar year prior to deductible, then $0 after deductible 3 $0 $0 $0 $0 $0 15% 20% 30% 40% 0% 15% 20% 30% 40% 0% $15 $40 30% 40% 0% $20 $50 30% 40% 0% $75 $250 $300 40% 0% 15% 20% 30% 40% 0% $5 $19 $19 40% 0% $15 $30 $ % 4 0% 4 $25 $50 $ % 4 0% 4 Not covered Not covered Not covered Not covered Not covered $15 $40 $60 40% 0% $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $500 per individual / $1,000 per family $1,500 per individual / $3,000 per family $5,000 per individual / $10,000 per family $4,500 per individual / $9,000 per family $6,350 per individual / $12,700 per family $2,250 per individual / $4,500 per family $5,200 per individual / $10,400 per family $6,350 per individual / $12,700 per family $6,350 per individual / $12,700 per family $6,350 per individual / $12,700 per family $50 per individual / $100 per family $250 per individual / $500 per family $0 4 $0 4 $0 4 * This Blue Shield plan must be purchased through Covered California. All other Blue Shield of California medical plans displayed on this chart can be purchased through Blue Shield or Covered California. 1 The amounts indicated are a percentage of the allowable amounts. Participating providers accept Blue Shield s allowable amounts as payment in full for covered services. 2 For family coverage, each individual must satisfy their own individual deductible, unless a combination of three or more covered family members satisfies the family deductible. This satisfies the deductible for all covered family members for the remainder of the year. This does not apply to HSA-compatible plans. 3 Visit limit is a combination of any physician office visit, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visit. 4 Brand drugs are subject to the calendar year medical deductible

18 Fully loaded coverage We have much more to offer than just medical coverage. We re the total package. You can get comprehensive coverage by adding dental, vision, and life insurance* plans from Blue Shield. It s our fully loaded options for healthcare coverage all in one convenient place. Family dental and vision coverage options Total health includes oral and vision health. If you have children, their dental and vision needs can be covered by one of our pediatric dental plans and the pediatric vision benefits we include in every medical plan. But what about you? For as little as $34.50 per month you can get complete coverage by adding valuable family dental and vision coverage to your medical coverage. * Life insurance is underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Rate is for a 21-year-old enrolled in the Enhanced Dental HMO $0 and Ultimate Vision 15/25/150 plans. CALIFORNIA

19 Family vision plan options Keep an eye on your vision health with a Blue Shield vision plan. The Ultimate Vision 15/25/150 plan* is a comprehensive vision plan that features a $150 frame allowance, and Specialty Duo* offers the convenience of dental and vision coverage in a single package. Both plans can be purchased with or without a medical plan. Benefit ULTIMATE VISION 15/25/150 SPECIALTY DUO SM DENTAL + VISION PACKAGE Allowance and copays with participating providers 1 : EYE EXAM (every 12 months) $15 copay $0 copay MATERIALS COPAY $25 copay $25 copay Frames $150 allowance (every 12 months) $100 allowance (every 24 months) Lenses Standard single vision, lined bifocal or lined trifocal with scratch coating $0 copay $0 copay Polycarbonate Lenses (only for Dependent children) $100 allowance $100 allowance Lens Options and Treatments Polycarbonate Lenses $160 allowance Not covered Progressive Lenses $115 allowance Not covered Anti-Reflective Lens Coating $140 allowance Not covered CONTACT LENSES 2 Medically necessary Elective (Cosmetic or Convenience) $25 copay $25 copay $120 allowance $120 allowance DIABETES MANAGEMENT REFERRAL $0 copay $0 copay DENTAL BENEFITS (includes coverage for preventive, diagnostic, minor services, and major services) None See the chart on the next page for more details = Benefit is available prior to meeting any deductible This chart is an overview of benefits. For additional benefit information, cost for services, waiting periods, and exclusions and limitations, please see the Benefit Summary Guide and Important Legal Information booklets. * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Ultimate Vision 15/25/150 is pending regulatory approval. 1 Participating providers accept Blue Shield s allowable amounts as payment-in-full for covered services. There is a 90-day waiting period for all services. 2 Contact lenses may be selected in lieu of eyeglasses. 1 7

20 Family dental plan options Protect your smile with one of our valuable dental plans, and you ll enjoy a broad range of benefits with access to a large network of providers. Add vision coverage as well to save on routine care such as eye exams, glasses, and contacts. We even offer a convenient dental + vision package Specialty Duo * to make it easy for you to get the best of both worlds with one simple purchase. All of our family dental plans can be purchased with or without a medical plan. Benefit Diagnostic and preventive services (includes but is not limited to cleanings, X-rays, initial and periodic oral examinations) * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Restorative services fillings (one surface resin composite) Oral surgery (includes but is not limited to extraction of erupted tooth or exposed root) Root canal (anterior root canal) Crowns (porcelain/ceramic substrate) Orthodontics Vision coverage (includes exam, frame, lenses, and contacts benefits) Calendar-year deductible 8 Calendar-year benefit 1 8

21 = Benefit is available prior to meeting any deductible = Benefit is subject to a deductible ENHANCED DENTAL PPO 50/1250 ENHANCED DENTAL PLUS PPO 50/1250 ENHANCED DENTAL PPO 25/500 ENHANCED DENTAL PLUS PPO 25/500 DENTAL PPO ENHANCED DENTAL HMO $0 DENTAL HMO SPECIALTY DUO DENTAL + VISION PACKAGE With participating providers, members pay 1 : 0% 0% 0% 0% $0 $0 $0 $0 20% 2 20% 2 20% 2 20% 2 $37 3 $20 $18 $ % 2 20% 2 20% 2 20% 2 $40 3 $40 $34 $ % 4 50% 4 50% 4 50% 4 $156 3 $175 $155 $ % 4 50% 4 50% 4 50% 4 $265 4 $350 5 $300 5 $265 4 Not covered 50% 4 (for children up to age 26 only; limitations apply 6 ) Not covered 50% 4 (for children up to age 26 only; limitations apply 7 ) $2,350 for child, fully banded, two year 4 $2,650 for adult, fully banded, two year 4 $2,350 for child, fully banded, two year $2,650 for adult, fully banded, two year $2,350 for child, fully banded, two year $2,650 for adult, fully banded, two year $2,350 for child, fully banded, two year 4 $2,650 for adult, fully banded, two year 4 Not covered Not covered Not covered Not covered Not covered Not covered Not covered See the family vision coverage section on the previous page for details $50 per individual / $150 per family $50 per individual / $150 per family $25 per individual / $75 per family $25 per individual / $75 per family $50 per individual $0 $0 $50 per individual $1,250 per individual $1,250 per individual $500 per individual $500 per individual $1,000 per individual None None $1,000 per individual This chart is an overview of benefits. For additional benefit information, cost for services, waiting periods, and exclusions and limitations, please see the Benefit Summary Guide and Important Legal Information booklets. 1 The amounts indicated are a percentage of the allowable amounts. Participating providers accept Blue Shield s allowable amounts as payment in full for covered services. 2 There is a six-month waiting period for these services. 3 There is a three-month waiting period for these services. 4 There is a 12-month waiting period for these services. 5 If precious metals are used, member will be charged at the dentist s cost. For Dental HMO, porcelain on molar teeth is subject to an additional charge of $ There is a $100 deductible for orthodontia, a $500 annual maximum benefit per child per year, and a $1,000 maximum per child per lifetime. 7 There is a $50 deductible for orthodontia, a $250 annual maximum benefit per child per year, and a $500 maximum per child per lifetime. 8 Applies to all services except diagnostic and preventive services. See footnotes 6 and 7 above for deductible requirements specific to orthodontics. 1 9

22 Pediatric dental plans Pediatric dental care is an essential health benefit that must be included with the purchase of every medical plan through Blue Shield (outside of Covered California). To expand your pediatric dental benefit options, we provide you with four different pediatric dental plans to choose from. Pediatric dental benefits are provided only to those under age 19. Because pediatric dental care is a federally mandated essential health benefit, every applicant (including adults) applying for a medical plan outside of the Exchange must select a pediatric dental plan. Although individuals age 19 and older must select a pediatric dental plan, they will not be eligible for benefits and the pediatric dental rate will not apply. Benefit PREFERRED DENTAL HMO PEDIATRIC $0 ENHANCED DENTAL HMO PEDIATRIC $20 PREFERRED DENTAL PPO PEDIATRIC 50/0 1 ENHANCED DENTAL PPO PEDIATRIC 60/0 1 Rates as low as $10.80 Rates as low as $9.60 Rates as low as $ Rates as low as $ With participating providers, members pay: Office visit $0 $20 N/A N/A Diagnostic and preventive services (includes but is not limited to cleanings, X-rays, initial and periodic oral examinations, topical fluoride treatment) $0 $0 0% 0% Restorative services fillings (amalgam or composite resin) $40 3 $ % 50% Oral surgery (removal of impacted teeth) Endodontics (root canal) Periodontics (root planing/scaling) $365 4 $ % 50% Crowns and fixed bridges (includes but is not limited to crowns [resin-based composite, porcelain, porcelain with metal, full metal, gold only, three-quarter crown, stainless steel] and fixed bridges [which are cast porcelain baked with metal or plastic processed to gold]) $365 4 $ % 50% Removable prosthetics (includes but is not limited to dentures [full maxillary, full mandibular, partial upper, partial lower, teeth, clasps, and stress breakers]) $365 4 $ % 50% Orthodontics (medically necessary) $1,000 $1,000 50% 50% Local and general anesthetics $0 $0 0% 0% Calendar-year deductible $0 $0 $50 per child / $100 per family $60 per child / $120 per family Calendar-year out-of-pocket maximum (includes deductible) $1,000 per child $1,000 per child $1,000 per child $1,000 per child (2 child max) 5 (2 child max) 5 (2 child max) 5 (2 child max) 5 Calendar-year benefit maximum per member N/A N/A No limit when using participating providers No limit when using participating providers = Benefit is available prior to meeting any deductible = Benefit is subject to a deductible This chart is an overview of benefits. For additional benefit information, cost for services, waiting periods, and exclusions and limitations, please see the Benefit Summary Guide and Important Legal Information booklets. 1 The amounts indicated are a percentage of the allowable amounts. Participating providers accept Blue Shield s allowable amounts as payment in full for covered services. 2 Rate is for a child under age 19 living in pricing regions and Copayments for basic services vary by procedures. The plan s average copay charged for procedures in this category cannot exceed the stated amount. 4 Copayments for major services vary by procedures. The plan s average copay charged for procedures in this category cannot exceed the stated amount. 5 For families with two or more children covered under this dental plan, the out-of-pocket maximum is limited to $2,000 for all children ($1,000 per child times a maximum of two children). 2 0

23 Individual term life insurance Facing financial burdens after the loss of a loved one can be overwhelming, and having life insurance helps. Individual term life insurance plans from Blue Shield Life can help safeguard the future of the significant people in your life your spouse, partner, or children by providing critical financial protection that can be used to cover living expenses, college education costs, mortgage payments, and more. Take a step toward safeguarding the financial future of those you care about by applying for life insurance coverage from Blue Shield of California Life & Health Insurance Company. We offer the financial protection and security of $10,000, $30,000, $60,000, $90,000, and $100,000 in term life insurance with low monthly rates based on your age. Age range $10,000 $30,000 $60,000 $90,000 $100,000 Available coverage amounts* 1 to 18 t $1.95 $2.95 N/A N/A N/A 19 to 29 $2.75 $5.35 $9.25 $13.15 $ to 39 $3.05 $6.25 $11.05 $15.85 $ to 49 $5.85 $14.65 $27.85 $41.05 $ to 59 $13.85 $38.65 $75.85 $ $ to 64 $20.45 $58.45 $ $ $ Coverage is available to all individuals, ages 1 to 64, with or without a Blue Shield health plan. Simply complete and submit the Application for Individual Term Life Insurance Coverage for consideration. Download the application at blueshieldca.com/bsca/find-a-plan/life-insurance-plans or call your broker today. * Individual term life insurance is available to applicants ages 1 to 64. All plans terminate at age 65. t Those under age 19 are not eligible for $60,000, $90,000, or $100,000 amounts of coverage. 2 1

24 Bumper-to-bumper help when you need it To keep you and your family running strong, we re proud to offer more than just healthcare coverage. For no extra cost, you ll get access to a variety of health and wellness tools and resources to help you maintain a healthy lifestyle and get the most out of your plan. Blueshieldca.com Keeping track of your coverage is just a click away. Log on to blueshieldca.com to access My Health Plan, where you can find out key details such as copayment and deductible amounts, check the status of a claim, and much more. Online decision support tools Take control of your health plan with our handy set of helpful tools. Get health reports, hospital comparisons, and pharmacy information to help you make informed decisions about your health care. Healthy lifestyle rewards If you re healthy, we don t just applaud you, we give you tools and resources to continue on your journey to promote a healthy lifestyle. Use our interactive online program, My Health Assistant Tool, to help reduce stress, manage your weight, quit smoking, exercise more, eat better, and improve emotional wellness. And take a Wellness Assessment to get recommendations on programs you can use to track progress toward achieving your health goals. NurseHelp 24/7 SM Sometimes, we just need to ask a helpful human a question about our health. Connect with a registered nurse online or on the phone, day or night, to get immediate answers and information for just about anything, including minor illnesses and injuries, chronic conditions, medical tests, medications, and preventive care. 2 22

25 Wellness discounts * We won t give you a gold medal for being the fittest of the fit. But for no additional cost, we do offer member discounts on programs to help you pursue a healthy lifestyle: 24 Hour Fitness Discounts on monthly dues and initiation costs, plus no enrollment or processing fees. ClubSport and Renaissance ClubSport Membership discounts. Weight Watchers Meeting vouchers, discounts on online subscriptions, and more. Alternative Care Discount Program Up to 25% off on care from participating acupuncture, chiropractic, and massage therapy practitioners, plus discounts on health and wellness products, including free shipping on most items. Discount Vision Program All Blue Shield members can save 20% on the services and materials listed below at participating providers whether or not they have vision care benefits through Blue Shield. Learn about participating providers on the Find a Provider page at blueshieldca.com/fap. Routine eye exams Frames and lenses (including photochromic) Tints and coatings Extra pair of glasses Non-prescription sunglasses Hard contact lenses To learn more about the wellness programs included alongside any Blue Shield plan, please visit blueshieldca.com/ wellnessdiscounts. * These discount program services are not a covered benefit of Blue Shield health plans, and none of the terms or conditions of Blue Shield health plans apply. Discount program services are available to all members with a Blue Shield medical, dental, vision, or life insurance plan. The networks of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy. Nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products. Some services offered through the discount program may already be included as part of the Blue Shield plan covered benefits. Members should access those covered services prior to using the discount program. Members who are not satisfied with products or services received from the discount program may use Blue Shield s grievance process described in the Grievance Process section of the Evidence of Coverage or Certificate of Insurance. Blue Shield reserves the right to terminate this program at any time without notice. Discount programs administered by or arranged through the following independent companies: Discount Vision Program and MESVisionOptics.com MESVision Weight control Weight Watchers North America Fitness facilities 24 Hour Fitness, ClubSport, and Renaissance ClubSport LASIK QualSight Inc., and NVISION Lasik Laser Eye Centers My2020EyesDirect.com Advanced Digital Eyewear Inc 2 3

26 Before we hand over the keys... Here are a few key terms that'll help guide you on the road ahead. With all the talk about deductibles and copayments, health care can sound like a foreign language. Here s a helpful translation of important words to help you better understand how health plans work. Brand drug A drug produced and sold under the original manufacturer s brand name. Many brand drugs are included in the Blue Shield Drug Formulary. Coinsurance A percentage of the cost for covered services that a member pays under the health plan. Copayment (or copay) A fixed dollar amount that a member pays for covered services under the health plan. Deductible The amount that a member pays for most covered services before the health plan pays for covered services. Evidence of Coverage The contract that defines the terms of health plan coverage. Non-participating provider A physician, hospital, or other licensed healthcare provider that is not contracted with Blue Shield to provide services to members in a Blue Shield of California or Blue Shield of California Life & Health Insurance Company PPO plan (also called a nonnetwork provider). Out-of-pocket maximum The dollar limit on the amount a member has to pay for specified covered services in a calendar year. For additional definitions, or for the contractual definitions of terms, ask for a copy of the Evidence of Coverage or Policy. 2 4

27 From all of us at Blue Shield of California, we wish you a happy and healthy road ahead.

28 Join Blue Shield for the road ahead. Visit us at blueshieldca.com. Blue Shield of California is an independent member of the Blue Shield Association OA44197-PPO (1/14) Covered California is a registered trademark of the State of California.