healthcare for the way we live

Transcription

1 healthcare for the way we live Enrollment Guide for Employees Aetna Anthem Blue Cross Health Net Kaiser Permanente Sharp Health Plan Western Health Advantage 1

2 CONTENTS Welcome to CaliforniaChoice... 3 What is CaliforniaChoice?... 3 How CaliforniaChoice works for you:... 3 What do you get?... 3 Coverage Options... 4 HMO... 4 Health Net Elect Open Access... 4 PPO... 4 Healthy Support... 4 Health Savings Account (HSA)... 4 Understanding Your Benefit Choices... 5 HMO Summary of Benefits PPO Summary of Benefits Consumer Directed Plans Summary of Benefits Healthy Support Plans Summary of Benefits Choosing Your Benefits Tools You ll Need to Enroll Look up your doctor Complete Your Application Personalized Worksheet Enrollment Application Waiver Form (attached to enrollment form) Family Coverage Coverage for spouse and children Coverage for domestic partner HMO Exclusions & Limitations and AB 88 Mental Health Parity PPO & Consumer Directed Plans Exclusions & Limitations Important Phone Numbers...Back Cover 2

3 WELCOME TO CALIFORNIACHOICE Healthcare for the way We Live Congratulations! Your employer has decided to offer health insurance coverage through CaliforniaChoice, giving you more options than any other program available in California. Now you can select the health plan of your choice and the benefits that are right for you and your family. What is CaliforniaChoice? CaliforniaChoice is a health insurance program that allows you to choose from multiple health plans and benefit options. How CaliforniaChoice works for you: n Allows you to customize a healthcare plan that meets your individual needs n Offers you more choices, greater flexibility and increased convenience n Provides you with more affordability, greater access, choice and satisfaction What do you get? n A selection of HMO, PPO, Healthy Support and HSA compatible plans to choose from n Prepaid, PPO and EPO dental plan options n Prescription benefit options n Vision, chiropractic/acupuncture and life services n The flexibility to change health plans during your annual renewal period n Outstanding customer service n Discounts on everything from theme parks to movies. Login to and start saving today. Your Health Plan Choices: 3

4 COVERAGE OPTIONS Your Benefit Choices HMO An HMO provides medical services through contracted physicians and hospitals. All healthcare services are managed in-network through your Primary Care Physician (PCP). n You first select a PCP (your doctor) n Referrals to hospitals and specialists are managed by your PCP n You pay a low copay for each office visit Health Net Elect Open Access An HMO benefit that has a self-referral feature to PPO doctors. n Elect Open Access is priced like an HMO but gives you access to PPO doctors through its network of more than 44,000 physicians n You first select a Primary Care Physician n Your PCP coordinates all your care including all major services such as hospitalization and surgery n You have unlimited access to any physician or specialist in the Health Net PPO network without a referral PPO* A PPO provides benefits within the health plan s network of doctors with the option of going out-of-network for higher costs. n PPOs do not require you to select a PCP n You can see any doctor but your benefits are not as rich when you see out-of-network doctors n You will pay less for seeing an in-network doctor n Pre-existing conditions may apply if you do not have prior medical coverage Healthy Support Our Healthy Support Plans offer access to a PPO network with cash incentives for healthy activities. Health Savings Account (HSA) HSAs offer great benefits with lower monthly premiums and the ability to save for future medical expenses - tax-free. n Contributions to your HSA are tax-deductible n Withdrawals from your HSA are tax-free when used for qualified medical expenses like doctor visits and prescriptions n Funds in your HSA keep earning tax-deferred interest year-after-year * PPO benefits are based on group size. Please see the top of page 13 for details. 4

5 UNDERSTANDING YOUR BENEFIT CHOICES HMO Benefits Under an HMO plan, all access to specialists and hospitalization must be determined through the member s Primary Care Physician (PCP). HMO Member Primary Care Physician Specialist Hospitalization Elect Open Access (Health Net only) Under the Elect Open Access plan, members must choose a Primary Care Physician (PCP). However, members may self-refer to any doctor in the Elect Open Access listing in the CaliforniaChoice Provider Directory. In-hospital benefits must be determined by a member's PCP. Elect Open Access Member Primary Care Physician In-Network PPO Physicans & Specialists Hospitalization PPO Benefits (Anthem Blue Cross Life and Health Insurance Company only) Under a PPO plan, members do not choose a Primary Care Physician (PCP). PPO members may self-refer to specialists. Members can receive care from 2 levels of in-network doctors or go out-of-network for lower benefits. PP0 Member In-Network Physician and Specialist Out-of-Network Physician and Specialist *whichever is greater, after deductible is met. In-Network Hospitalization or Out-of-Network Hospitalization Health Savings Account (HSA) Benefits (Anthem Blue Cross Life and Health Insurance Company only) Members receive comprehensive medical coverage and have the option to contribute tax-deductible funds into a Health Savings Account (HSA) and accumulate tax-deferred interest. HSA members do not pay taxes on withdrawals when paying for qualified medical expenses. *HSA - Qualified High Deductible Health Plan HSA* 1800 HSA* 2500 Low Monthly Premiums HSA Accumulate interest tax-free and use funds for qualified medical expenses 80% after deductible after deductible In-Network Physician Copay Out-of-Network Physician Copay 5

6 HMO SUMMARY OF BENEFITS Services Available Through: Calendar Year Deductible Lifetime Maximum Professional Services (Office Visits) Physician services, (office, specialists other than surgery or therapy); allergy testing, treatment and serum, diagnostic x-ray and lab Professional Services (Diagnostic) Laboratory services; diagnostic and therapeutic radiological services and other diagnostic services, including electrocardiography (EKG) and electroencephalography (EEG) Professional Services (Preventive) 1 Routine physical exams on a periodic age-appropriate basis; prenatal services; breast and pelvic exams; pap smears; cervical cancer screening; mammography for screening purposes; immunizations for children and adults; preventive care for children; well baby care Out-Patient Surgery Services Surgical Facility Hospitalization Services (In-patient) General hospital services, including semi-private room; intensive care unit and services; drugs; medications; anesthesia and oxygen services; diagnostic x-ray and lab Hospital Pregnancy & Maternity Care Emergency Room/Health Coverage Copay waived if admitted to hospital Ambulance Services (per trip) Physical, Occupational, Speech Therapy 2 Prescriptions 3 Per 30 day supply or 100 unit doses, HCSP is allowed to use a generic or formulary brand Durable Medical Equipment (Covered when medically necessary as determined by HCSP) 4, 11 Mental Health Out-Patient Visits Infertility Evaluation and Treatment Copay Maximum (per calendar year) CalChoice HMO 15 5 CalChoice HMO 25 5,12 CalChoice HMO 25 5 CalChoice HMO 25 5 CalChoice HMO 25 5 Aetna 12, Anthem Blue Cross 6, Health Net 6, Kaiser Permanente, Sharp, Western Health Advantage $15 $ Copay - $100 $50 $15 $10 Generic $20 Brand 11 $15 Generic $100 Ded. - Brand $100 $15 Generic $100 Ded. - Brand $15 Generic $100 Ded. - Brand $100 $10 Generic Brand Non-Formulary Rx Coverage varies by health plan. See Health Plan & Formulary Comparison Guide. Covered at 90% 8 $2,000 Sgl. $4,000 Fam. Aetna Anthem Blue Cross 6 Health Net 6 Kaiser Permanente 7 $450 Copay per day Max. $1,800 $150 Covered at 8 or as stated in Plan s EOC $2,500 Sgl. $5,000 Fam. 7 0 $450 Copay per day Max. $1,800 $150 Covered at $3,000 Sgl. $6,000 Fam. 7 0 $450 Copay per day Max. $1,800 $150 Covered at 8 $3,000 Sgl. $6,000 Fam. $ Copay - $150 Covered at $2,500 Sgl. $5,000 Fam. 1 Please see your Evidence of Coverage to confirm if specific benefits fall under the preventive category. 2 For Aetna and Anthem Blue Cross, provided for an aggregate of 60 consecutive days following illness or injury. Additional visits will be covered as authorized by medical group or healthcare service provider if medically necessary. 3 For Anthem Blue Cross - If a member selects a brand-name drug when a generic-equivalent is available, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the genericequivalent drug unless the physician writes dispense as written or do not substitute. The amount paid does not apply to the member s brand-name deductible as applicable. 4 For Anthem Blue Cross, pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment or you will be required to pay a 0 Copayment if pre-service review is not obtained; and 2) Out-Patient professional services after twelve visits. 5 Copayment shall be up to the designated amount, or of the provider s contracted rate, whichever is less. 6 Anthem Blue Cross and Health Net offer the option of an additional provider network. Those additional options are noted as: Anthem Blue Cross Select HMO and Health Net Silver HMO (not available in all counties in California). Prior to enrollment, the employer may elect to offer the standard network OR these provider networks to their employees. 7 The copay for an MRI, CT or PET scan is $ visits per year (Provisions of AB 88 apply - see page 27) 9 The copay for an MRI, CT or PET scan is $ Salud HMO y Más benefits are for the Salud Network. Please see Salud Application/Brochure for SIMNSA Network benefits. 11 Please see your plan specific EOC for additional information. 12 Aetna plans are available in the Aetna Value Network (AVN) only. Note: Not available in all counties in California. Prior to enrollment the employer may elect to offer the Aetna Value Network to their employees. Note: These services are covered benefits only when and to the extent that they are provided, or directed by the Healthcare Service Plan (HCSP) you have selected, except in emergencies. Each HCSP is responsible for administering these benefits pursuant to its administrative procedures, medical protocols and medical review criteria and procedures. The benefits are subject to various limitations, exclusions and conditions, as noted on page 21 and fully described in each HCSP s Evidence of Coverage document and program regulations. If you would like more information prior to enrollment, or wish to request an Evidence of Coverage document, please contact the HCSP(s) you are interested in, using the telephone number listed on the back of this brochure. All services covered by your selected HCSP are fully described in the EOC document that will be mailed to you once you have enrolled and are accepted for coverage through the CaliforniaChoice Program. This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). 6 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

7 HMO SUMMARY OF BENEFITS Services CalChoice HMO CalChoice HMO 25 CalChoice Value HMO 25 CalChoice HMO Value CalChoice HMO 25 Value Available Through: Sharp Western Health Advantage Aetna Anthem Blue Cross 6 Health Net 6 Calendar Year Deductible Lifetime Maximum Professional Services (Office Visits) Physician services, (office, specialists other than surgery or therapy); allergy testing, treatment and serum, diagnostic x-ray and lab Professional Services (Diagnostic) Laboratory services; diagnostic and therapeutic radiological services and other diagnostic services, including electrocardiography (EKG) and electroencephalography (EEG) Professional Services (Preventive) 1 Routine physical exams on a periodic age-appropriate basis; prenatal services; breast and pelvic exams; pap smears; cervical cancer screening; mammography for screening purposes; immunizations for children and adults; preventive care for children; well baby care Out-Patient Surgery Services Surgical Facility Hospitalization Services (In-patient) General hospital services, including semi-private room; intensive care unit and services; drugs; medications; anesthesia and oxygen services; diagnostic x-ray and lab Hospital Pregnancy & Maternity Care Emergency Room/Health Coverage Copay waived if admitted to hospital Ambulance Services (per trip) Physical, Occupational, Speech Therapy 2 Prescriptions 3 Per 30 day supply or 100 unit doses, HCSP is allowed to use a generic or formulary brand Durable Medical Equipment (Covered when medically necessary as determined by HCSP) 4, 11 Mental Health Out-Patient Visits Infertility Evaluation and Treatment Copay Maximum (per calendar year) 0 0 Copay per day Max. $1,200 $150 $100 $15 Generic $100 Ded. - Brand $100 $15 Generic $100 Ded. - Brand 11 $20 Copay Ded. - Brand $100 $15 Generic Ded. - Brand $15 Generic $100 Ded. - Brand Non-Formulary Rx Coverage varies by health plan. See Health Plan & Formulary Comparison Guide. Covered at 8 $2,500 Sgl. $5,000 Fam. 0 0 Copay per day Max. $1,200 $150 Covered at $2,500 Sgl. $5,000 Fam. 1 Please see your Evidence of Coverage to confirm if specific benefits fall under the preventive category. 2 For Aetna and Anthem Blue Cross, provided for an aggregate of 60 consecutive days following illness or injury. Additional visits will be covered as authorized by medical group or healthcare service provider if medically necessary. 3 For Anthem Blue Cross - If a member selects a brand-name drug when a generic-equivalent is available, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the genericequivalent drug unless the physician writes dispense as written or do not substitute. The amount paid does not apply to the member s brand-name deductible as applicable. 4 For Anthem Blue Cross, pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment or you will be required to pay a 0 Copayment if pre-service review is not obtained; and 2) Out-Patient professional services after twelve visits. 5 Copayment shall be up to the designated amount, or of the provider s contracted rate, whichever is less. 6 Anthem Blue Cross and Health Net offer the option of an additional provider network. Those additional options are noted as: Anthem Blue Cross Select HMO and Health Net Silver HMO (not available in all counties in California). Prior to enrollment, the employer may elect to offer the standard network OR these provider networks to their employees. 7 The copay for an MRI, CT or PET scan is $ visits per year (Provisions of AB 88 apply - see page 27) 9 The copay for an MRI, CT or PET scan is $ Salud HMO y Más benefits are for the Salud Network. Please see Salud Application/Brochure for SIMNSA Network benefits. 11 Please see your plan specific EOC for additional information. 12 Aetna plans are available in the Aetna Value Network (AVN) only. Note: Not available in all counties in California. Prior to enrollment the employer may elect to offer the Aetna Value Network to their employees. Note: These services are covered benefits only when and to the extent that they are provided, or directed by the Healthcare Service Plan (HCSP) you have selected, except in emergencies. Each HCSP is responsible for administering these benefits pursuant to its administrative procedures, medical protocols and medical review criteria and procedures. The benefits are subject to various limitations, exclusions and conditions, as noted on page 21 and fully described in each HCSP s Evidence of Coverage document and program regulations. If you would like more information prior to enrollment, or wish to request an Evidence of Coverage document, please contact the HCSP(s) you are interested in, using the telephone number listed on the back of this brochure. All services covered by your selected HCSP are fully described in the EOC document that will be mailed to you once you have enrolled and are accepted for coverage through the CaliforniaChoice Program. This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). 7 $550 Copay per day Max. $1,650 $150 Covered at 8 or as stated in Plan s EOC $3,000 Sgl. $6,000 Fam. $1,000 Sgl./$2,000 Fam. (Applies to Copay Max) 7 80% after deductible 80% after deductible $150 after deductible Covered at $3,000 Sgl. $6,000 Fam. 7 75% 75% $150 Covered at 8 $3,000 Sgl. $6,000 Fam. THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. 7

8 HMO SUMMARY OF BENEFITS Services Elect Open Access 25 Plus Elect Open Access 25 Salud HMO y Más 10 CalChoice HMO 30 5,12 CalChoice HMO 30 5 Available Through: Health Net 6 Health Net 6 Health Net Aetna Anthem Blue Cross 6 Calendar Year Deductible Lifetime Maximum Professional Services (Office Visits) Physician services, (office, specialists other than surgery or therapy); allergy testing, treatment and serum, diagnostic x-ray and lab Copay HMO Copay PPO Copay HMO Copay PPO Professional Services (Diagnostic) Laboratory services; diagnostic and therapeutic radiological services and other diagnostic services, including electrocardiography (EKG) and electroencephalography (EEG) Professional Services (Preventive) 1 Routine physical exams on a periodic age-appropriate basis; prenatal services; breast and pelvic exams; pap smears; cervical cancer screening; mammography for screening purposes; immunizations for children and adults; preventive care for children; well baby care Out-Patient Surgery Services Surgical Facility 0 Copay 75% 0 0 Hospitalization Services (In-patient) General hospital services, including semi-private room; intensive care unit and services; drugs; medications; anesthesia and oxygen services; diagnostic x-ray and lab Hospital Pregnancy & Maternity Care $450 Copay per day Max. $1,800 75% $500 Copay per day Max. $1,000 $450 Copay per day Max. $1,800 $450 Copay per day Max. $1,800 Emergency Room/Health Coverage Copay waived if admitted to hospital $150 $150 $100 Ambulance Services (per trip) Physical, Occupational, Speech Therapy 2 $50 11 Prescriptions 3 Per 30 day supply or 100 unit doses, HCSP is allowed to use a generic or formulary brand Durable Medical Equipment (Covered when medically necessary as determined by HCSP) $15 Generic $100 Ded. - Brand Covered at $15 Generic $100 Ded. - Brand $15 Copay $150 Ded. - Brand Non-Formulary Rx Coverage varies by health plan. See Health Plan & Formulary Comparison Guide. Covered at $15 Generic Brand Covered at Covered at $15 Generic $150 Ded. - Brand Covered at 4, 11 Mental Health Out-Patient Visits Infertility Evaluation and Treatment or as stated in Plan s EOC Copay Maximum (per calendar year) $3,000 Ind. $6,000 Two Party $7,000 Fam. $3,000 Ind. $6,000 Two Party $7,000 Fam. $2,500 Sgl. $5,000 Fam. $3,000 Sgl. $6,000 Fam. $3,000 Sgl. $6,000 Fam. 1 Please see your Evidence of Coverage to confirm if specific benefits fall under the preventive category. 2 For Aetna and Anthem Blue Cross, provided for an aggregate of 60 consecutive days following illness or injury. Additional visits will be covered as authorized by medical group or healthcare service provider if medically necessary. 3 For Anthem Blue Cross - If a member selects a brand-name drug when a generic-equivalent is available, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the genericequivalent drug unless the physician writes dispense as written or do not substitute. The amount paid does not apply to the member s brand-name deductible as applicable. 4 For Anthem Blue Cross, pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment or you will be required to pay a 0 Copayment if pre-service review is not obtained; and 2) Out-Patient professional services after twelve visits. 5 Copayment shall be up to the designated amount, or of the provider s contracted rate, whichever is less. 6 Anthem Blue Cross and Health Net offer the option of an additional provider network. Those additional options are noted as: Anthem Blue Cross Select HMO and Health Net Silver HMO (not available in all counties in California). Prior to enrollment, the employer may elect to offer the standard network OR these provider networks to their employees. 7 The copay for an MRI, CT or PET scan is $ visits per year (Provisions of AB 88 apply - see page 27) 9 The copay for an MRI, CT or PET scan is $ Salud HMO y Más benefits are for the Salud Network. Please see Salud Application/Brochure for SIMNSA Network benefits. 11 Please see your plan specific EOC for additional information. 12 Aetna plans are available in the Aetna Value Network (AVN) only. Note: Not available in all counties in California. Prior to enrollment the employer may elect to offer the Aetna Value Network to their employees. Note: These services are covered benefits only when and to the extent that they are provided, or directed by the Healthcare Service Plan (HCSP) you have selected, except in emergencies. Each HCSP is responsible for administering these benefits pursuant to its administrative procedures, medical protocols and medical review criteria and procedures. The benefits are subject to various limitations, exclusions and conditions, as noted on page 21 and fully described in each HCSP s Evidence of Coverage document and program regulations. If you would like more information prior to enrollment, or wish to request an Evidence of Coverage document, please contact the HCSP(s) you are interested in, using the telephone number listed on the back of this brochure. All services covered by your selected HCSP are fully described in the EOC document that will be mailed to you once you have enrolled and are accepted for coverage through the CaliforniaChoice Program. This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). 8 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

9 HMO SUMMARY OF BENEFITS Services CalChoice HMO 30 5 CalChoice HMO 30 5 CalChoice HMO 30 5 CalChoice HMO 30 5 CalChoice HMO 30 Value 12 Available Through: Health Net 6 Kaiser Permanente Sharp Western Health Advantage Aetna Calendar Year Deductible Lifetime Maximum Professional Services (Office Visits) Physician services, (office, specialists other than surgery or therapy); allergy testing, treatment and serum, diagnostic x-ray and lab Professional Services (Diagnostic) Laboratory services; diagnostic and therapeutic radiological services and other diagnostic services, including electrocardiography (EKG) and electroencephalography (EEG) Professional Services (Preventive) 1 Routine physical exams on a periodic age-appropriate basis; prenatal services; breast and pelvic exams; pap smears; cervical cancer screening; mammography for screening purposes; immunizations for children and adults; preventive care for children; well baby care Out-Patient Surgery Services Surgical Facility Hospitalization Services (In-patient) General hospital services, including semi-private room; intensive care unit and services; drugs; medications; anesthesia and oxygen services; diagnostic x-ray and lab Hospital Pregnancy & Maternity Care Emergency Room/Health Coverage Copay waived if admitted to hospital Ambulance Services (per trip) Physical, Occupational, Speech Therapy 2 Prescriptions 3 Per 30 day supply or 100 unit doses, HCSP is allowed to use a generic or formulary brand Durable Medical Equipment (Covered when medically necessary as determined by HCSP) 4, 11 Mental Health Out-Patient Visits Infertility Evaluation and Treatment Copay Maximum (per calendar year) 7 0 $450 Copay per day Max. $1,800 $ $450 Copay - 11 $15 Generic $15 Generic $15 Generic $15 Generic $20 Copay $150 Ded. - Brand Brand $150 Ded. - Brand $150 Ded. - Brand Ded. - Brand Non-Formulary Rx Coverage varies by health plan. See Health Plan & Formulary Comparison Guide. Covered at 8 $3,000 Sgl. $6,000 Fam. Covered at $3,000 Sgl. $6,000 Fam. 1 Please see your Evidence of Coverage to confirm if specific benefits fall under the preventive category. 2 For Aetna and Anthem Blue Cross, provided for an aggregate of 60 consecutive days following illness or injury. Additional visits will be covered as authorized by medical group or healthcare service provider if medically necessary. 3 For Anthem Blue Cross - If a member selects a brand-name drug when a generic-equivalent is available, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the genericequivalent drug unless the physician writes dispense as written or do not substitute. The amount paid does not apply to the member s brand-name deductible as applicable. 4 For Anthem Blue Cross, pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment or you will be required to pay a 0 Copayment if pre-service review is not obtained; and 2) Out-Patient professional services after twelve visits. 5 Copayment shall be up to the designated amount, or of the provider s contracted rate, whichever is less. 6 Anthem Blue Cross and Health Net offer the option of an additional provider network. Those additional options are noted as: Anthem Blue Cross Select HMO and Health Net Silver HMO (not available in all counties in California). Prior to enrollment, the employer may elect to offer the standard network OR these provider networks to their employees. 7 The copay for an MRI, CT or PET scan is $ visits per year (Provisions of AB 88 apply - see page 27) 9 The copay for an MRI, CT or PET scan is $ Salud HMO y Más benefits are for the Salud Network. Please see Salud Application/Brochure for SIMNSA Network benefits. 11 Please see your plan specific EOC for additional information. 12 Aetna plans are available in the Aetna Value Network (AVN) only. Note: Not available in all counties in California. Prior to enrollment the employer may elect to offer the Aetna Value Network to their employees. Note: These services are covered benefits only when and to the extent that they are provided, or directed by the Healthcare Service Plan (HCSP) you have selected, except in emergencies. Each HCSP is responsible for administering these benefits pursuant to its administrative procedures, medical protocols and medical review criteria and procedures. The benefits are subject to various limitations, exclusions and conditions, as noted on page 21 and fully described in each HCSP s Evidence of Coverage document and program regulations. If you would like more information prior to enrollment, or wish to request an Evidence of Coverage document, please contact the HCSP(s) you are interested in, using the telephone number listed on the back of this brochure. All services covered by your selected HCSP are fully described in the EOC document that will be mailed to you once you have enrolled and are accepted for coverage through the CaliforniaChoice Program. This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). 9 0 $450 Copay per day Max. $1,800 Covered at 8 $3,000 Sgl. $6,000 Fam. 9 0 $450 Copay per day Max. $1,800 Covered at $3,000 Sgl. $6,000 Fam. 7 0 $650 Copay per day Max. $1,950 Covered at 8 or as stated in Plan s EOC $3,500 Sgl. $7,000 Fam. THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. 9

10 HMO SUMMARY OF BENEFITS Services CalChoice HMO 30 Value CalChoice HMO 30 Value CalChoice HMO 40 5,12 CalChoice HMO 40 5 CalChoice HMO 40 5 CalChoice HMO 40 5 Available Through: Health Net 6 Sharp Aetna Anthem Blue Cross 6 Health Net 6 Kaiser Permanente Calendar Year Deductible Lifetime Maximum Professional Services (Office Visits) Physician services, (office, specialists other than surgery or therapy); allergy testing, treatment and serum, diagnostic x-ray and lab Professional Services (Diagnostic) Laboratory services; diagnostic and therapeutic radiological services and other diagnostic services, including electrocardiography (EKG) and electroencephalography (EEG) Professional Services (Preventive) 1 Routine physical exams on a periodic age-appropriate basis; prenatal services; breast and pelvic exams; pap smears; cervical cancer screening; mammography for screening purposes; immunizations for children and adults; preventive care for children; well baby care Out-Patient Surgery Services Surgical Facility Hospitalization Services (In-patient) General hospital services, including semi-private room; intensive care unit and services; drugs; medications; anesthesia and oxygen services; diagnostic x-ray and lab Hospital Pregnancy & Maternity Care Emergency Room/Health Coverage Copay waived if admitted to hospital Ambulance Services (per trip) Physical, Occupational, Speech Therapy 2 Prescriptions 3 Per 30 day supply or 100 unit doses, HCSP is allowed to use a generic or formulary brand Durable Medical Equipment (Covered when medically necessary as determined by HCSP) 4, 11 Mental Health Out-Patient Visits Infertility Evaluation and Treatment Copay Maximum (per calendar year) 10 7 $1,000 Sgl./$2,000 Fam. after deductible 13 after deductible 13 $150 after deductible $150 after deductible 11 $20 Generic $20 Generic $20 Generic $20 Generic $20 Generic $15 Generic Ded. - Brand $150 Ded. - $35 Brand Ded. - Brand Ded. - Brand Ded. - Brand Brand Non-Formulary Rx Coverage varies by health plan. See Health Plan & Formulary Comparison Guide. Covered at 8 $3,500 Sgl. $7,000 Fam. Covered at after deductible, Max. $2,000 per year 13 8, after deductible 13 $3,500 Sgl. $7,000 Fam. 1 Please see your Evidence of Coverage to confirm if specific benefits fall under the preventive category. 2 For Aetna and Anthem Blue Cross, provided for an aggregate of 60 consecutive days following illness or injury. Additional visits will be covered as authorized by medical group or healthcare service provider if medically necessary. 3 For Anthem Blue Cross - If a member selects a brand-name drug when a generic-equivalent is available, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the genericequivalent drug unless the physician writes dispense as written or do not substitute. The amount paid does not apply to the member s brand-name deductible as applicable. 4 For Anthem Blue Cross, pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment or you will be required to pay a 0 Copayment if pre-service review is not obtained; and 2) Out-Patient professional services after twelve visits. 5 Copayment shall be up to the designated amount, or of the provider s contracted rate, whichever is less. 6 Anthem Blue Cross and Health Net offer the option of an additional provider network. Those additional options are noted as: Anthem Blue Cross Select HMO and Health Net Silver HMO (not available in all counties in California). Prior to enrollment, the employer may elect to offer the standard network OR these provider networks to their employees. 7 The copay for an MRI, CT or PET scan is $ visits per year (Provisions of AB 88 apply - see page 27) 9 The copay for an MRI, CT or PET scan is $ Salud HMO y Más benefits are for the Salud Network. Please see Salud Application/Brochure for SIMNSA Network benefits. 11 Please see your plan specific EOC for additional information. 12 Aetna plans are available in the Aetna Value Network (AVN) only. Note: Not available in all counties in California. Prior to enrollment the employer may elect to offer the Aetna Value Network to their employees. 13 Of contracted rates. Note: These services are covered benefits only when and to the extent that they are provided, or directed by the Healthcare Service Plan (HCSP) you have selected, except in emergencies. Each HCSP is responsible for administering these benefits pursuant to its administrative procedures, medical protocols and medical review criteria and procedures. The benefits are subject to various limitations, exclusions and conditions, as noted on page 21 and fully described in each HCSP s Evidence of Coverage document and program regulations. If you would like more information prior to enrollment, or wish to request an Evidence of Coverage document, please contact the HCSP(s) you are interested in, using the telephone number listed on the back of this brochure. All services covered by your selected HCSP are fully described in the EOC document that will be mailed to you once you have enrolled and are accepted for coverage through the CaliforniaChoice Program. This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. 7 0 $500 Copay per day 0 Covered at 8 or as stated in Plan s EOC $3,500 Sgl. $7,000 Fam. 7 $500 $500 Copay per day 0 Covered at $3,500 Sgl. $7,000 Fam. 7 $500 $500 Copay per day 0 Covered at $50 8 $3,500 Sgl. $7,000 Fam. $10 9 $500 $500 Copay per day 0 Covered at $3,500 Sgl. $7,000 Fam.

11 HMO SUMMARY OF BENEFITS Services CalChoice HMO 40 5 CalChoice HMO 40 5 CalChoice HMO 40 Value 12 CalChoice HMO 40 Value CalChoice HMO 40 Value Available Through: Sharp Western Health Advantage Aetna Anthem Blue Cross 6 Health Net 6 Calendar Year Deductible $1,500 Sgl./$3,000 Fam. (Applies to Copay Max) Lifetime Maximum Professional Services (Office Visits) Physician services, (office, specialists other than surgery or therapy); allergy testing, treatment and serum, diagnostic x-ray and lab Professional Services (Diagnostic) Laboratory services; diagnostic and therapeutic radiological services and other diagnostic services, including electrocardiography (EKG) and electroencephalography (EEG) Professional Services (Preventive) 1 Routine physical exams on a periodic age-appropriate basis; prenatal services; breast and pelvic exams; pap smears; cervical cancer screening; mammography for screening purposes; immunizations for children and adults; preventive care for children; well baby care Out-Patient Surgery Services Surgical Facility $500 $500 0 after deductible 60% Hospitalization Services (In-patient) General hospital services, including semi-private room; intensive care unit and services; drugs; medications; anesthesia and oxygen services; diagnostic x-ray and lab Hospital Pregnancy & Maternity Care $500 Copay per day $500 Copay per day $750 Copay per day Max. $2,250 after deductible 60% Emergency Room/Health Coverage Copay waived if admitted to hospital after deductible 0 Ambulance Services (per trip) Physical, Occupational, Speech Therapy 2 11 Prescriptions 3 Per 30 day supply or 100 unit doses, HCSP is allowed to use a generic or formulary brand Durable Medical Equipment (Covered when medically necessary as determined by HCSP) $20 Generic Ded. - Brand Covered at $20 Generic Ded. - Brand $20 Generic Ded. - Brand $15 Generic 0 Ded. - Brand Non-Formulary Rx Coverage varies by health plan. See Health Plan & Formulary Comparison Guide. Covered at Covered at Covered at $20 Generic Ded. - Brand Covered at 4, 11 Mental Health Out-Patient Visits $ $50 8 Infertility Evaluation and Treatment or as stated in Plan s EOC Copay Maximum (per calendar year) $3,500 Sgl. $7,000 Fam. $3,500 Sgl. $7,000 Fam. $3,500 Sgl. $7,000 Fam. $4,000 Sgl. $8,000 Fam. $3,500 Sgl. $7,000 Fam. 1 Please see your Evidence of Coverage to confirm if specific benefits fall under the preventive category. 2 For Aetna and Anthem Blue Cross, provided for an aggregate of 60 consecutive days following illness or injury. Additional visits will be covered as authorized by medical group or healthcare service provider if medically necessary. 3 For Anthem Blue Cross - If a member selects a brand-name drug when a generic-equivalent is available, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the genericequivalent drug unless the physician writes dispense as written or do not substitute. The amount paid does not apply to the member s brand-name deductible as applicable. 4 For Anthem Blue Cross, pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment or you will be required to pay a 0 Copayment if pre-service review is not obtained; and 2) Out-Patient professional services after twelve visits. 5 Copayment shall be up to the designated amount, or of the provider s contracted rate, whichever is less. 6 Anthem Blue Cross and Health Net offer the option of an additional provider network. Those additional options are noted as: Anthem Blue Cross Select HMO and Health Net Silver HMO (not available in all counties in California). Prior to enrollment, the employer may elect to offer the standard network OR these provider networks to their employees. 7 The copay for an MRI, CT or PET scan is $ visits per year (Provisions of AB 88 apply - see page 27) 9 The copay for an MRI, CT or PET scan is $ Salud HMO y Más benefits are for the Salud Network. Please see Salud Application/Brochure for SIMNSA Network benefits. 11 Please see your plan specific EOC for additional information. 12 Aetna plans are available in the Aetna Value Network (AVN) only. Note: Not available in all counties in California. Prior to enrollment the employer may elect to offer the Aetna Value Network to their employees. Note: These services are covered benefits only when and to the extent that they are provided, or directed by the Healthcare Service Plan (HCSP) you have selected, except in emergencies. Each HCSP is responsible for administering these benefits pursuant to its administrative procedures, medical protocols and medical review criteria and procedures. The benefits are subject to various limitations, exclusions and conditions, as noted on page 21 and fully described in each HCSP s Evidence of Coverage document and program regulations. If you would like more information prior to enrollment, or wish to request an Evidence of Coverage document, please contact the HCSP(s) you are interested in, using the telephone number listed on the back of this brochure. All services covered by your selected HCSP are fully described in the EOC document that will be mailed to you once you have enrolled and are accepted for coverage through the CaliforniaChoice Program. This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. 11

12 HMO SUMMARY OF BENEFITS Services CalChoice HMO 40 Value CalChoice HMO 40 Value Elect Open Access 40 Plus Available Through: Sharp Western Health Advantage Health Net 6 Calendar Year Deductible Lifetime Maximum Professional Services (Office Visits) Physician services, (office, specialists other than surgery or therapy); allergy testing, treatment and serum, diagnostic x-ray and lab $1,500 Sgl./$3,000 Fam. $2,500 Sgl./$5,000 Fam. (Applies to Copay Max) Copay HMO $55 Copay PPO Professional Services (Diagnostic) Laboratory services; diagnostic and therapeutic radiological services and other diagnostic services, including electrocardiography (EKG) and electroencephalography (EEG) 9 7 Professional Services (Preventive) 1 Routine physical exams on a periodic age-appropriate basis; prenatal services; breast and pelvic exams; pap smears; cervical cancer screening; mammography for screening purposes; immunizations for children and adults; preventive care for children; well baby care Out-Patient Surgery Services Surgical Facility 60% after deductible 12 0 $500 Copay Hospitalization Services (In-patient) General hospital services, including semi-private room; intensive care unit and services; drugs; medications; anesthesia and oxygen services; diagnostic x-ray and lab Hospital Pregnancy & Maternity Care 60% after deductible 12 $500 Copay per day after deductible $ 500 Copay per day Emergency Room/Health Coverage Copay waived if admitted to hospital $150 after deductible 0 after deductible 0 Ambulance Services (per trip) Physical, Occupational, Speech Therapy 2 Prescriptions 3 Per 30 day supply or 100 unit doses, HCSP is allowed to use a generic or formulary brand Durable Medical Equipment (Covered when medically necessary as determined by HCSP) Mental Health Out-Patient Visits 4,11 $150 after deductible $50 $20 Generic $20 Generic $20 Generic $150 Ded. - $35 Brand 0 Ded. - Brand Ded. - Brand Non-Formulary Rx Coverage varies by health plan. See Health Plan & Formulary Comparison Guide. Covered at after deductible, Max. $2,000 per year 12 8 Covered at 80% Covered at 8 Infertility Evaluation and Treatment, after deductible Copay Maximum (per calendar year) $4,000 Sgl. $8,000 Fam. $5,000 Sgl. $10,000 Fam. THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. $3,500 Ind. $7,000 Two Party $8,000 Fam. 1 Please see your Evidence of Coverage to confirm if specific benefits fall under the preventive category. 2 For Aetna and Anthem Blue Cross, provided for an aggregate of 60 consecutive days following illness or injury. Additional visits will be covered as authorized by medical group or healthcare service provider if medically necessary. 3 For Anthem Blue Cross - If a member selects a brand-name drug when a generic-equivalent is available, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic-equivalent drug unless the physician writes dispense as written or do not substitute. The amount paid does not apply to the member s brand-name deductible as applicable. 4 For Anthem Blue Cross, pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment or you will be required to pay a 0 Copayment if preservice review is not obtained; and 2) Out-Patient professional services after twelve visits. 5 Copayment shall be up to the designated amount, or of the provider s contracted rate, whichever is less. 6 Anthem Blue Cross and Health Net offer the option of an additional provider network. Those additional options are noted as: Anthem Blue Cross Select HMO and Health Net Silver HMO (not available in all counties in California). Prior to enrollment, the employer may elect to offer the standard network OR these provider networks to their employees. 7 The copay for an MRI, CT or PET scan is $ visits per year (Provisions of AB 88 apply - see page 27) 9 The copay for an MRI, CT or PET scan is $ Salud HMO y Más benefits are for the Salud Network. Please see Salud Application/Brochure for SIMNSA Network benefits. 11 Please see your plan specific EOC for additional information. 12 Of contracted rates. Note: These services are covered benefits only when and to the extent that they are provided, or directed by the Healthcare Service Plan (HCSP) you have selected, except in emergencies. Each HCSP is responsible for administering these benefits pursuant to its administrative procedures, medical protocols and medical review criteria and procedures. The benefits are subject to various limitations, exclusions and conditions, as noted on page 21 and fully described in each HCSP s Evidence of Coverage document and program regulations. If you would like more information prior to enrollment, or wish to request an Evidence of Coverage document, please contact the HCSP(s) you are interested in, using the telephone number listed on the back of this brochure. All services covered by your selected HCSP are fully described in the EOC document that will be mailed to you once you have enrolled and are accepted for coverage through the CaliforniaChoice Program. This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable).

13 PPO SUMMARY OF BENEFITS PPO plans available through Anthem Blue Cross Life and Health Insurance Company PPO Mix and Match Guidelines Total Group Size Plans Available 2-9 medically enrolled employees 10+ medically enrolled employees All HMO and HMO Value; PPO 750 GenRx, PPO 1000, PPO 1000 GenRx, PPO 3000, PPO 4000, HSA 1800, HSA 2500, PPO 1500, PPO 1750 GenRx. All HMO and HMO Value; Refer to Employee enrollment worksheet for PPO availability Deductible, Copay and Out-of-Pocket Maximum CalChoice PPO 750 CalChoice PPO 750 GenRx CalChoice PPO 1000 CalChoice PPO 1000 GenRx Calendar Year Deductibles* n Individual $ 750 $ 750 $ 1,000 $ 1,000 n Family of 2 $ 1,500 $ 1,500 $ 2,000 $ 2,000 n Family of 3 or more $ 2,250 $ 2,250 $ 3,000 $ 3,000 Out-Of-Pocket Maximum 1 In-Network Providers** n Individual $ 4,000 $ 4,500 $ 5,000 $ 5,000 n Family $ 8,000 $ 9,000 $ 10,000 $ 10,000 (includes deductible) (includes deductible) (includes deductible) (includes deductible) Out-of-Network Providers $ 10,000 2 $ 10,000 2 $ 10,000 2 $ 10,000 2 Lifetime Maximum Benefits CalChoice PPO 750 CalChoice PPO 750 GenRx CalChoice PPO 1000 CalChoice PPO 1000 GenRx In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Physician Services Out-Patient PCP or OB Visit Specialist Office Visit Mammogram and PAP Test $35 Copay 7,9 $35 Copay 7,9 $35 Copay $35 Copay 7,9 $35 Copay 7,9 $35 Copay Copay 7,9 Copay 7,9 Copay $45 Copay 7,9 $45 Copay 7,9 $45 Copay Laboratory, X-Ray & Diagnostic Deductible Applies Physician Services In-Patient In-Patient visits and consultations Surgeons, assistants, anesthesiologists, pathologists, radiologists 80% 80% 80% (Max $800 benefit for Advanced Imaging) 65% 65% 65% (Max $800 benefit for Advanced Imaging) (Max $800 benefit for Advanced Imaging) (Max $800 benefit for Advanced Imaging) Preventive Benefits Not subject to cal. yr. deductible Annual Physical Exam Eye/ear screening, immunizations Mammogram and Pap Test Laboratory Hospital Services Out-Patient Out-Patient surgery Ambulatory Surgery Center Hospital Pre-Authorization $500 Copay 80% 0 Copay 80% (Up to $380 per admission) 4 (Up to $380 per admission) 4 OON Required or additional 0 Copay applies $500 Copay 65% 0 Copay 65% (Up to $380 per admission) 4 (Up to $380 per admission) 4 OON Required or additional 0 Copay applies $500 Copay 0 Copay (Up to $380 per admission) 4 (Up to $380 per admission) 4 OON Required or additional 0 Copay applies $500 Copay 0 Copay (Up to $380 per admission) 4 (Up to $380 per admission) 4 OON Required or additional 0 Copay applies Hospital Services In-Patient Room, Board, Service and Supplies $500 Copay (Up to $500 Copay (Up to $1,000 Copay (Up to $500 Copay (Up to 80% $650 per day) 4 65% $650 per day) 4 $650 per day) 4 $650 per day) 4 Hospital Pre-Authorization OON Required or additional OON Required or additional OON Required or additional OON Required or additional 0 Copay xxapplies 0 Copay xxapplies 0 Copay xxapplies xx 0 Copay xxapplies Pregnancy & Maternity Care Prenatal and postnatal care 80% 65% All necessary In-Patient hospital services Covered under In-Patient Hospital * Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder of that calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible. ** Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than the individual maximum copayment limit toward the family maximum. THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. 13

14 PPO SUMMARY OF BENEFITS Benefits CalChoice PPO 750 CalChoice PPO 750 GenRx CalChoice PPO 1000 CalChoice PPO 1000 GenRx In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network In-Network Out-of-Network Emergency Services All necessary In-Patient hospital services ER Facility and ER Physician Services (Not Resulting in Admission) $150 (waived if admitted)-80% $150 (waived if admitted)-80% $150 (waived if admitted)-65% Covered under In-Patient Hospital $150 (waived if admitted)-65% $150 (waived if admitted)- $150 (waived if admitted)- $150 (waived if admitted)- $150 (waived if admitted)- Ambulance 80% 65% Physical, Occupational Therapy and Chiropractic Care Durable Medical Equipment 80% (up to per visit) % (up to per visit) 4 Maximum 24 visits per year 6 (up to per visit) 4 6 (up to per visit) 4 6 Drug & Alcohol Benefits, Mental & Nervous Benefits 3 In-Patient Out-Patient Hospice Routine Home Care Skilled Nursing Facility Max 100 days per year Home Health Care Infertility Evaluation and Treatment Acupuncture $500 Copay - 80% $35 Copay % 80% $500 Copay - 80% 80% (Up to per visit) (Up to $650 per day) 4 (Up to $150 per day) 4 (Up to $75 per visit) 4 $500 Copay $500 Copay - 65% $35 Copay % 65% $500 Copay - 65% (Up to $650 per day) 4 $1,000 Copay - Copay 9 9 (Up to $150 per day) 4 (Up to $75 per visit) 4 Maximum 100 visits per year $500 Copay $500 Copay $500 Copay - $45 Copay 9 9 Lifetime Max. $2,000 Lifetime Max. $2,000 Lifetime Max. $2,000 Lifetime Max. $2,000 (Up to per visit) 4 65% (Up to per visit) (Up to per visit) 4 (Up to per visit) (Up to per visit) 4 (Up to per visit) Maximum 24 visits per year. (Up to $650 per day) 4 (Up to $150 per day) 4 (Up to $75 per visit) 4 $500 Copay $500 Copay (Up to $650 per day) 4 (Up to $150 per day) 4 (Up to $75 per visit) 4 $500 Copay (Up to per visit) 4 Prescription Costs Participating Pharmacy PPO 750*/ PPO 1000** Non-Participating Pharmacy PPO 750*/ PPO 1000** Mail Service Prescriptions PPO 750*/ PPO 1000** Participating Pharmacy PPO 750 GenRx/ PPO 1000 GenRx Non-Participating Pharmacy PPO 750 GenRx/ PPO 1000 GenRx Mail Service Prescriptions PPO 750 GenRx/ PPO 1000 GenRx Out-Patient Prescription Drugs (Includes oral contraceptives) Generic Drugs Formulary Brand Drugs 5 Non-Formulary Brand Drugs 5 $15 $50 of maximum allowed amount when filled in California 6 of maximum allowed amount when filled in California 6 of maximum allowed amount when filled in California 6 For up to a 90 day supply $15 $60 $100 $15 8 of maximum allowed amount when filled in California 6,8 For up to a 90 day supply $ * A separate $ 150 per individual deductible applies to formulary and non-formulary brand drugs. ** A separate $ 200 per individual deductible applies to formulary and non-formulary brand drugs. *** A separate $ 250 per individual deductible applies to formulary and non-formulary brand drugs. Note: For non-emergency care, out-of-network reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Members are responsible for the difference between the provider s usual charges & the maximum allowed amount. Non-participating hospitals are covered at a reduced benefit. For medical emergency care rendered by a non-participating provider or non-contracting hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value. Plans exclude coverage for pre-existing conditions (except for members under age 19, a child acquired through legal guardianship if the child is added within 31 days of final court decree or order, a child born to or newly adopted by an enrolled subscriber or spouse, or conditions of pregnancy) for the first six months of coverage unless replacing prior creditable coverage. 1 The following do not apply to the out-of-pocket maximum: inpatient, outpatient and ambulatory surgical facility copays, applicable pharmacy deductibles and copays for pharmacy benefits, copays for acupuncture/acupressure, copays for not obtaining preservice review; infertility copay; and non-covered expenses. After a member reaches the out- of-pocket maximum in a calendar year, the member will no longer be required to pay a copay for the remainder of that year, except as stated in the Certificate. The insured remains responsible for these amounts even after the out-of-pocket maximum has been met. 2 Once Anthem Blue Cross payments reach $10,000 per insured, the insured pays nothing for covered expenses for the remainder of the year. 3 Pre-service review is required for the following mental or nervous disorders and substance abuse services; 1) Facility-based treatment or you will be required to pay a 0 copayment if pre-service review is not obtained for non-participating providors; and 2) Out-Patient professional services after twelve visits. 4 The coverage amount listed is the maximum allowed charge for non-emergency services received from a non-participating hospital or non-participating provider. Members are responsible for all charges in excess of the covered amount. Physician Services are covered separately at of Allowable Amounts. 5 If a member selects a brand-name drug when a generic-equivalent is available, even if the physician writes dispense as written or do not substitute, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug. The amount paid does not apply to the member s pharmacy deductible, if applicable. 6 Members are responsible for all charges in excess of the maximum allowed amount. 7 The dollar copay applies only to the visit itself. An additional copay applies for any services performed in office (i.e., x-ray, lab, surgery), after any applicable deductible. 8 This prescription drug plan includes coverage for drugs on the GenRx Prescription Drug Formulary only. 9 Deductible waived. Note: This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

15 PPO plans available through Anthem Blue Cross Life and Health Insurance Company PPO Mix and Match Guidelines Total Group Size Plans Available PPO SUMMARY OF BENEFITS 2-9 medically enrolled employees 10+ medically enrolled employees All HMO and HMO Value; PPO 750 GenRx, PPO 1000, PPO 1000 GenRx, PPO 3000, PPO 4000, HSA 1800, HSA 2500, PPO 1500, PPO 1750 GenRx. All HMO and HMO Value; Refer to Employee enrollment worksheet for PPO availability Deductible, Copay and Out-of-Pocket Maximum Calendar Year Deductibles* CalChoice PPO 3000 CalChoice PPO 4000 n Individual $ 3,000 $ 4,000 n Family of 2 $ 6,000 $ 8,000 n Family of 3 or more $ 9,000 $ 10,000 Out-Of-Pocket Maximum 1 In-Network Providers** n Individual $ 7,000 $ 7,000 n Family $ 14,000 $ 14,000 (includes deductible) (includes deductible) Out-of-Network Providers $ 10,000 2 $ 10,000 2 Lifetime Maximum Benefits CalChoice PPO 3000 CalChoice PPO 4000 In-Network Out-of-Network In-Network Out-of-Network Physician Services Out-Patient PCP or OB Visit Specialist Office Visit Mammogram and PAP Test Copay 7,9 Copay 7,9 Copay Copay 7,9 Copay 7,9 Copay Laboratory, X-Ray & Diagnostic Deductible Applies (Max $800 benefit for Advanced Imaging) 60% (Max $800 benefit for Advanced Imaging) Physician Services In-Patient In-Patient visits and consultations Surgeons, assistants, anesthesiologists, pathologists, radiologists 60% 60% Preventive Benefits Not subject to cal. yr. deductible Annual Physical Exam Eye/ear screening, immunizations Mammogram and Pap Test Laboratory Hospital Services Out-Patient Out-Patient surgery Ambulatory Surgery Center Hospital Pre-Authorization Hospital Services In-Patient Room, Board, Service and Supplies Hospital Pre-Authorization Pregnancy & Maternity Care Prenatal and postnatal care All necessary In-Patient hospital services $500 Copay 0 Copay $500 Copay (Up to $380 per admission) 4 (Up to $380 per admission) 4 OON Required or additional 0 Copay applies (Up to $650 per day) 4 OON Required or additional 0 Copay applies xx $500 Copay 60% 0 Copay 60% $500 Copay 60% 60% Covered under In-Patient Hospital (Up to $380 per admission) 4 (Up to $380 per admission) 4 OON Required or additional 0 Copay applies (Up to $650 per day) 4 OON Required or additional 0 Copay applies xx * Under a family contract, when an insured satisfies the individual deductible amount, no further deductible is required for that insured for the remainder of that calendar year; however, an insured may not contribute an amount greater than the individual deductible toward the family deductible. ** Under a family contract, an insured can satisfy their individual out-of-pocket maximum; however, an insured may not contribute an amount greater than the individual maximum copayment limit toward the family maximum. THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. 15

16 PPO SUMMARY OF BENEFITS Benefits CalChoice PPO 3000 CalChoice PPO 4000 In-Network Out-of-Network In-Network Out-of-Network Emergency Services All necessary In-Patient hospital services ER Facility and ER Physician Services (Not Resulting in Admission) $150 (waived if admitted)- Covered under In-Patient Hospital $150 (waived if admitted)- $150 (waived if admitted)-60% $150 (waived if admitted)-60% Ambulance Physical, Occupational Therapy and Chiropractic Care (Up to per visit) 4 Durable Medical Equipment 60% (Up to 60% per visit) 4 Maximum 24 visits per year 6 6 Drug & Alcohol Benefits, Mental & Nervous Benefits 3 In-Patient Out-Patient Hospice Routine Home Care (ded. waived) Skilled Nursing Facility Max 100 days per year Home Health Care Infertility Evaluation and Treatment Acupuncture $500 Copay - Copay 9 9 (Up to $650 per day) 4 $500 Copay - 60% Copay 9 (Up to $650 per day) 4 9 (Up to $150 per day) 4 60% (Up to $150 per day) 4 (Up to 60% (Up to $75 per visit) 4 $75 per visit) 4 Maximum 100 visits per year $500 Copay - $500 Copay $500 Copay - 60% $500 Copay Lifetime Max. $2,000 Lifetime Max. $2,000 (Up to per visit) (Up to per visit) 4 60% (Up to per visit) (Up to per visit) 4 Maximum 24 visits per year. Prescription Costs Participating Pharmacy PPO 3000***/PPO 4000*** Non-Participating Pharmacy PPO 3000***/PPO 4000*** Mail Service Prescriptions PPO 3000***/PPO 4000*** Out-Patient Prescription Drugs (Includes oral contraceptives) For up to a 90 day supply Generic Drugs Formulary Brand Drugs 5 Non-Formulary Brand Drugs 5 $15 $50 of maximum allowed amount when filled in California 6 of maximum allowed amount when filled in California 6 of maximum allowed amount when filled in California 6 $15 $60 $ * A separate $ 150 per individual deductible applies to formulary and non-formulary brand drugs. ** A separate $ 200 per individual deductible applies to formulary and non-formulary brand drugs. *** A separate $ 250 per individual deductible applies to formulary and non-formulary brand drugs. Note: For non-emergency care, out-of-network reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Members are responsible for the difference between the provider s usual charges & the maximum allowed amount. Non-participating hospitals are covered at a reduced benefit. For medical emergency care rendered by a non-participating provider or non-contracting hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value. Plans exclude coverage for pre-existing conditions (except for members under age 19, a child acquired through legal guardianship if the child is added within 31 days of final court decree or order, a child born to or newly adopted by an enrolled subscriber or spouse, or conditions of pregnancy) for the first six months of coverage unless replacing prior creditable coverage. 1 The following do not apply to the out-of-pocket maximum: inpatient, outpatient and ambulatory surgical facility copays, applicable pharmacy deductibles and copays for pharmacy benefits, copays for acupuncture/acupressure, copays for not obtaining preservice review; infertility copay; and non-covered expenses. After a member reaches the out- of-pocket maximum in a calendar year, the member will no longer be required to pay a copay for the remainder of that year, except as stated in the Certificate. The insured remains responsible for these amounts even after the out-of-pocket maximum has been met. 2 Once Anthem Blue Cross payments reach $10,000 per insured, the insured pays nothing for covered expenses for the remainder of the year. 3 Pre-service review is required for the following mental or nervous disorders and substance abuse services; 1) Facility-based treatment or you will be required to pay a 0 copayment if pre-service review is not obtained for non-participating providors; and 2) Out-Patient professional services after twelve visits. 4 The coverage amount listed is the maximum allowed charge for non-emergency services received from a non-participating hospital or non-participating provider. Members are responsible for all charges in excess of the covered amount. Physician Services are covered separately at of Allowable Amounts. 5 If a member selects a brand-name drug when a generic-equivalent is available, even if the physician writes dispense as written or do not substitute, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug. The amount paid does not apply to the member s pharmacy deductible, if applicable. 6 Members are responsible for all charges in excess of the maximum allowed amount. 7 The dollar copay applies only to the visit itself. An additional copay applies for any services performed in office (i.e., x-ray, lab, surgery), after any applicable deductible. 8 This prescription drug plan includes coverage for drugs on the GenRx Prescription Drug Formulary only. 9 Deductible waived. Note: This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

17 Calendar Year Deductible (Individual/Family aggregate) CONSUMER DIRECTED PLANS SUMMARY OF BENEFITS Lumenos HSA 1800* Lumenos HSA 2500* In-Network Out-of-Network In-Network Out-of-Network $1,800 ind./$3,600 fam. 1 $1,800 ind./$3,600 fam. 1 $2,500 ind./$5,000 fam. 1 $2,500 ind./$5,000 fam. 1 (medical and pharmacy combined) (medical and pharmacy combined) (medical and pharmacy combined) (medical and pharmacy combined) Lifetime Maximum Physician Services Out-Patient Office visit/consultations (not including routine exams) 80% 80% Specialist visits and consultations 80% 80% Laboratory, x-rays, diagnostics 80% 80% (Max $800 benefit for Advanced Imaging) (Max $800 benefit for Advanced Imaging) Physician Services In-Patient In-Patient visits and consultations 80% 80% Surgeons and assistants, anesthesiologists, pathologists, radiologists 80% 80% Preventive Benefits Annual Routine Physical Exam (one per calendar year) (ded. waived) (ded. waived) See Plan s Certificate for details of covered benefits Hospital Services Out-Patient 80% (Up to $380 80% (Up to $380 Out-Patient surgery Renal dialysis per admission) 5 per admission) 5 Hospital Pre-Authorization Required Hospital Services In-Patient Semi-private room and board, medically necessary services and supplies, including subacute care 80% (Up to 80% (Up to $650 per day) 5 $650 per day) 5 Hospital Pre-Authorization Pregnancy & Maternity Care Prenatal and postnatal care 80% Required 80% All necessary In-Patient hospital services Covered under In-Patient Hospital Emergency Services $150 (waived if $150 (waived if $150 (waived if $150 (waived if admitted)-80% admitted)-80% admitted)-80% admitted)-80% Ambulance 80% 80% Physical, Occupational Therapy and Chiropractic Care 80% (Up to 80% (Up to per visit) 5 per visit) 5 Maximum 24 visits per year Note: For non-emergency care, out-of-network reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Members are responsible for the difference between the provider s usual charges & the maximum allowed amount. Non-participating hospitals are covered at a reduced benefit. For medical emergency care rendered by a non-participating provider or non-contracting hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value. Plans exclude coverage for pre-existing conditions (except for members under age 19, a child acquired through legal guardianship if the child is added within 31 days of final court decree or order, a child born to or newly adopted by an enrolled subscriber or spouse, or conditions of pregnancy) for the first six months of coverage unless replacing prior creditable coverage. * HSA-Qualified High Deductible Health Plan. 1 Employees enrolling for single coverage must satisfy the single deductible; for employees enrolling with Dependent coverage, the family deductible must be met before any member receives benefits. 2 If a member selects a brand-name drug when a generic-equivalent is available, even if the physician writes dispense as written or do not substitute, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic-equivalent drug. 3 Pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment; and 2) Out-Patient professional services after twelve visits. 4 The following do not apply to the out-of-pocket maximum: charges paid for acupuncture/acupressure by non-participating providers and non-covered expenses. The insured remains responsible for these amounts even after the out-of-pocket maximum has been met. 5 The coverage amount listed is the maximum allowed charge for non-emergency services received from a non-participating hospital or non-participating provider. Members are responsible for all charges in excess of the covered amount. Physician Services are covered separately at of Allowable Amounts. 6 Our reimbursement within the state of California is listed. Members are responsible for all charges in excess of the maximum allowed amount. The submission of a prescription drug claim is required for reimbursement of out-of-network pharmacies. Note: This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. 17

18 CONSUMER DIRECTED PLANS SUMMARY OF BENEFITS Lumenos HSA 1800* Lumenos HSA 2500* In-Network Out-of-Network In-Network Out-of-Network Durable Medical Equipment Drug & Alcohol Benefits, Mental & Nervous Benefits 3 (severe and non-severe) Out-Patient 80% 80% In-Patient 80% (Up to 80% (Up to $650 per day) 5 $650 per day) 5 Hospice Routine Home Care 80% 80% Home Health Care 80% (Up to 80% (Up to $75 per visit) 5 $75 per visit) 5 Skilled Nursing Facility 80% (Up to 80% (Up to $150 per day) 5 $150 per day) 5 Acupuncture 80% (up to per visit) Maximum 100 visits per year Maximum 100 days per year (Up to per visit) 5 80% (up to per visit) (Up to per visit) 5 Maximum 24 visits per year Infertility Evaluation and Treatment 80% 80% $2,000 Maximum Lifetime Benefit $2,000 Maximum Lifetime Benefit Out-of-Pocket Maximum 4 (Individual/Family) Includes Plan Deductible and Pharmacy covered expenses $3,000/$5,500 $3,000/$5,500 $4,000/$6,000 $4,000/$6,000 Prescription Costs Participating Pharmacy Non-Participating Pharmacy Mail Service Prescriptions Out-Patient Drugs 2 (subject to medical deductible, includes oral contraceptives) For up to a 90 day supply Generic Drugs $15 of maximum allowed amount 6 $15 Formulary Drugs of maximum allowed amount 6 $60 Non-Formulary Drugs $50 of maximum allowed amount 6 $100 Note: For non-emergency care, out-of-network reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Members are responsible for the difference between the provider s usual charges & the maximum allowed amount. Non-participating hospitals are covered at a reduced benefit. For medical emergency care rendered by a non-participating provider or non-contracting hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value. Plans exclude coverage for pre-existing conditions (except for members under age 19, a child acquired through legal guardianship if the child is added within 31 days of final court decree or order, a child born to or newly adopted by an enrolled subscriber or spouse, or conditions of pregnancy) for the first six months of coverage unless replacing prior creditable coverage. * HSA-Qualified High Deductible Health Plan. 1 Employees enrolling for single coverage must satisfy the single deductible; for employees enrolling with Dependent coverage, the family deductible must be met before any member receives benefits. 2 If a member selects a brand-name drug when a generic-equivalent is available, even if the physician writes dispense as written or do not substitute, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic-equivalent drug. 3 Pre-service review is required for the following mental or nervous disorders and substance abuse services: 1) Facility-based treatment; and 2) Out-Patient professional services after twelve visits. 4 The following do not apply to the out-of-pocket maximum: charges paid for acupuncture/acupressure by non-participating providers and non-covered expenses. The insured remains responsible for these amounts even after the out-of-pocket maximum has been met. 5 The coverage amount listed is the maximum allowed charge for non-emergency services received from a non-participating hospital or non-participating provider. Members are responsible for all charges in excess of the covered amount. Physician Services are covered separately at of Allowable Amounts. 6 Our reimbursement is listed. Members are responsible for all charges in excess of the maximum allowed amount. The submission of a prescription drug claim is required for reimbursement of out-of-network pharmacies. Note: This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated, is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). 18 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

19 HEALTHY SUPPORT SUMMARY OF BENEFITS Deductible, Copay and Out-of-Pocket Maximum CalChoice PPO 1500 In-Network Out-of-Network CalChoice PPO 1750 GenRx In-Network Out-of-Network Calendar Year Deductibles n Individual $ 1,500 $ 3,000 $ 1,750 $ 3,500 n Family $ 4,500 $ 9,000 $ 5,200 $ 10,400 Out-Of-Pocket Maximum 1 n Individual $ 5,000 $ 10,000 $ 6,000 $ 12,000 n Family $ 10,000 $ 20,000 $ 12,000 $ 24,000 Lifetime Maximum Benefits CalChoice PPO 1500 In-Network Out-of-Network CalChoice PPO 1750 GenRx In-Network Out-of-Network Physician Services Out-Patient PCP or OB Visit Specialist Office Visit Mammogram and PAP Test 4 (ded. waived) 4 (ded. waived) $45 4 (ded. waived) $45 4 (ded. waived) Laboratory, X-Ray & Diagnostic Deductible Applies Physician Services In-Patient In-Patient visits and consultations (Max $800 Benefit for Advanced Imaging) (Max $800 Benefit for Advanced Imaging) Surgeons, assistants, anesthesiologists, pathologists, radiologists Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Tier 1 Tier 2 Preventive Benefits Not subject to cal. yr. deductible Annual Physical Exam Eye/ear screening, immunizations Mammogram and Pap Test Laboratory Hospital Services Out-Patient Out-Patient surgery Ambulatory Surgery Center Hospital Pre-Authorization Hospital Services In-Patient Room, Board, Service and Supplies Hospital Pre-Authorization Pregnancy & Maternity Care Prenatal and postnatal care All necessary In-Patient hospital services Tier 1 2 $500 Copay - Tier 2 2 $750 Copay - 60% OON Only Required or Additional 0 Copay applies (Up to $380 Per Admission) 3 (Up to $380 Per Admission) 3 Tier 1 2 $1,000 Copay - (Up to $650 Per Day) 3 Tier 2 2 $1,500 Copay - 60% OON Only Required or Additional 0 Copay applies Tier 1 2 $500 Copay - Tier 2 2 $750 Copay - $45 Covered under In-Patient Hospital (Up to $380 Per Admission) 3 (Up to $380 Per Admission) 3 OON Only Required or Additional 0 Copay applies Tier 1 2 $1,000 Copay - (Up to $650 Per Day) 3 Tier 2 2 $1,500 Copay - OON Only Required or Additional 0 Copay applies Note: For non-emergency care, out-of-network reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Members are responsible for the difference between the provider s usual charges & the maximum allowed amount. Non-participating hospitals are covered at a reduced benefit. For medical emergency care rendered by a non-participating provider or non-contracting hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value. Plans exclude coverage for pre-existing conditions (except for members under age 19, a child acquired through legal guardianship if the child is added within 31 days of final court decree or order, a child born to or newly adopted by an enrolled subscriber or spouse, or conditions of pregnancy) for the first six months of coverage unless replacing prior creditable coverage. 1 The following do not apply to the out-of-pocket maximum: inpatient, outpatient and ambulatory surgical facility copays, applicable pharmacy deductibles and copays for pharmacy benefits, copays for acupuncture/acupressure, copays for not obtaining preservice review; infertility copay; and non-covered expenses. After a member reaches the out-of-pocket maximum in a calendar year, the member will no longer be required to pay a copay for the remainder of that year, except as stated in the Certificate. The insured remains responsible for these amounts even after the out-of-pocket maximum has been met. 2 The hospital you choose will determine the benefit level payable under the plan. By choosing a Tier 1 Preferred Participating Hospital, you will receive the highest level of benefits available under this plan. To view the Tier level of the participating hospitals go to and click on the Provider/Rx search link. 3 The coverage amount listed is the maximum allowed charge for non-emergency services received from a non-participating hospital or non-participating provider. Members are responsible for all charges in excess of the covered amount. Physician Services are covered separately at of Allowable Amounts. 4 The dollar copay applies only to the visit itself. An additional copay applies for any services performed in office (i.e., x-ray, lab, surgery), after any applicable deductible. Note: This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. 19

20 HEALTHY SUPPORT SUMMARY OF BENEFITS Benefits CalChoice PPO 1500 In-Network Out-of-Network CalChoice PPO 1750 GenRx In-Network Out-of-Network Emergency Services All necessary In-Patient hospital services Covered under In-Patient Hospital ER Facility and ER Physician Services (Not Resulting in Admission) Tier (waived if admitted) - Tier (waived if admitted) - 60% 0 (waived if admitted) - 60% Tier (waived if admitted) - Tier (waived if admitted) - 0 (waived if admitted) - Ambulance Physical, Occupational Therapy and Chiropractic Care Durable Medical Equipment Drug & Alcohol Benefits, Mental & Nervous Benefits 2 In-Patient Out-Patient Tier 1 4 $1,000 Copay - Tier 2 4 $1,500 Copay - 60% Copay (deductible waived) (Up to Per Visit)5 Maximum 24 visits per year (Up to $650 Per Day) 5 Tier 1 4 $1,000 Copay - Tier 2 4 $1,500 Copay - $45 Copay (deductible waived) (Up to Per Visit)5 (Up to $650 Per Day) 5 Hospice Routine Home Care Skilled Nursing Facility Max 100 days per year (deductible waived) (Up to $150 Per Day) 5 (deductible waived) (Up to $150 Per Day) 5 Home Health Care Infertility Evaluation and Treatment $500 Copay - (Up to $75 Per visit) Maximum 100 visits per year $500 Copay - $500 Copay - Lifetime Max. $2,000 (Up to $75 Per visit) $500 Copay - Acupuncture (Up to per visit) (Up to per visit) Maximum 24 visits per year (Up to per visit) (Up to per visit) Prescription Costs Participating Pharmacy PPO 1500* Non-Participating Pharmacy PPO 1500* Mail Service Prescriptions PPO 1500* Participating Pharmacy PPO 1750 GenRx Non-Participating Pharmacy PPO 1750 GenRx Mail Service Prescriptions PPO 1750 GenRx Out-Patient Prescription Drugs (Includes oral contraceptives) Generic Drugs Formulary Drugs Non-Formulary Brand Drugs $15 $35 Copay 6,7 of maximum allowed amount when filled in California of maximum allowed amount when filled in California of maximum allowed amount when filled in California For up to a 90 day supply $15 $70 $15 8 of maximum allowed amount when filled in California * A separate $500 per individual deductible applies to formulary and non-formulary brand drugs. For up to a 90 day supply $15 Note: For non-emergency care, out-of-network reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Members are responsible for the difference between the provider s usual charges & the maximum allowed amount. Non-participating hospitals are covered at a reduced benefit. For medical emergency care rendered by a non-participating provider or non-contracting hospital, reimbursement is based on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value. Plans exclude coverage for pre-existing conditions (except for members under age 19, a child acquired through legal guardianship if the child is added within 31 days of final court decree or order, a child born to or newly adopted by an enrolled subscriber or spouse, or conditions of pregnancy) for the first six months of coverage unless replacing prior creditable coverage. 1 The following do not apply to the out-of-pocket maximum: inpatient, outpatient and ambulatory surgical facility copays, applicable pharmacy deductibles and copays for pharmacy benefits, copays for acupuncture/acupressure, copays for not obtaining preservice review; infertility copay; and non-covered expenses. After a member reaches the out-of-pocket maximum in a calendar year, the member will no longer be required to pay a copay for the remainder of that year, except as stated in the Certificate. The insured remains responsible for these amounts even after the out-of-pocket maximum has been met. 2 Pre-service review is required for the following mental or nervous disorders and substance abuse services; 1) Facility-based treatment (non-participating providers) or you will be required to pay a 0 copayment if pre-service review is not obtained; and 2) Outpatient professional services after twelve visits. 3 The dollar copay applies only to the visit itself. An additional copay applies for any services performed in office (i.e., x-ray, lab, surgery), after any applicable deductible. 4 The hospital you choose will determine the benefit level payable under the plan. By choosing a Tier 1 Preferred Participating Hospital, you will receive the highest level of benefits available under this plan. To view the Tier level of the participating hospitals go to and click on the Provider/Rx search link. 5 The coverage amount listed is the maximum allowed charge for non-emergency services received from a non-participating hospital or non-participating provider. Members are responsible for all charges in excess of the covered amount. Physician Services are covered separately at of Allowable Amounts. 6 This prescription drug plan includes coverage for drugs on the Generic Premium Prescription Drug Formulary only. 7 If a member selects a brand-name drug when a generic-equivalent is available, even if the physician writes a dispense as written or do not substitute, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug. The amount paid does not apply to the member s pharmacy deductible, if applicable. 8 This prescription drug plan includes coverage for drugs on the GenRx Prescription Drug Formulary only. Note: This summary of benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This summary of benefits, as updated is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care (as applicable). 20 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE CERTIFICATE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

21 Social Security # required! Social Security # required! Social Security # required! Social Security # required! Steve Shorr CHOOSING YOUR BENEFITS It s easy to choose the right benefits with CaliforniaChoice because we lay it out all for you; from how much your employer is contributing to your benefits, to how much each benefit is for you and/or your dependents to enroll. Tools You ll Need to Enroll CaliforniaChoice Program EMPLOYEE ENROLLMENT WORKSHEET Effective Date: 03/01/13 SAMPLE QUOTE-RIVERSIDE All Prepaid Dental benefits are covered In-Network only. Quote #: EMPLOYEE #1 - Age 26 Employer Zip Code: Residence Zip Code: Medical / Dental / Life / Vision Enrollment Application Prepaid Dental Plans Plan 3000 Plan 1000 EPO/PPO Dental Plans EPO 3000➂ EPO 3500➂ PPO 4000➂ PPO 5000➂ Application must be COMPLETED in FULL, SIGNED and DATED for processing. IF YOU ARE WAIVING COVERAGE, YOU MUST COMPLETE, SIGN AND DATE WAIVER ON PAGE 5 OF THIS APPLICATION. Exams and Diagnostics In-Network EPO Network EPO Network PPO Network PPO Network Annual Deductible No Deductible $ 50 $1,200 $1,600 No Deductible Charge No Charge 3x/Fam) $ 25 (Max 3x/Fam) Waived Ded. Waived No Charge Maximum $1,000 $1,000 No Annual Deductible Initial Oral Exam (Max 3x/Fam) $ 50 (Max 3x/Fam) $ 25 (Max Preventive Care Ded. No Charge Ded. Waived Ded. Waived Please select one: New Hire Enrollment New Renewal Enrollment New COBRA Enrollment A. PERSONAL INFORMATION New Enrollment/Qualifying Event No 80% 80%/90%/➅ No Charge No Charge ➃ Periodontics 80%/90%/➅ Charge No Charge Basic Bite Wing X-Ray Major 80%➃ Endo & ➃ ➃ ➃ 80%/90%/➅ ➃ 80% Restorative Orthodontia Adult Cavities - Amalgam, 1 Surface $ 9 Copay No Charge Cavities - Amalgam, 2 Surfaces $ 14 Copay No Charge Orthodontia Children (maximum age 18) Crowns Out-of-Network -No Annual Max -No Annual Max -No Annual Max $1000 Lifetime ➄ $1000 Lifetime ➄ $1000 Lifetime ➄ Name of Company Employer Phone # Employee Job Title Full-time Employment Date Sex M F Status Married Single (Note: If you or any of your dependents are not enrolling, you must also complete and sign the waiver section on page 5.) Domestic Partner Employee Last Name Employee Social Security Number $ 225 Copay➀ $ 175 Copay➀ Full Cast Noble Metal $ 115 Copay➀ $ 60 Copay➀ Annual Deductible $ 100 (Max 3x/Fam) $ 50 (Max 3x/Fam) $ 75 (Max 3x/Fam) $ 75 (Max 3x/Fam) Preventive Care Ded. Waived Ded. Applies Ded. Applies Ded. Applies Porcelain - Base Metal (Posterior) Annual Maximum $ 600 $1,000 $1,000 $1,300 Periodontics Preventive➁ 80% 80% 80% Employee First Name Middle Initial Date of Birth MO DAY YEAR Group Number 30 Copay No Charge Periodontal Scaling & Root Planing (quadrant) 26 Copay $ 20 Copay $ $ Major 80% ➃ 80% 80% ➃ Endo & ➃ ➃ ➃ ➃ ➃ ➃ 100 Copay $ 40 Copay Single Root Canal Bi-Root Canal Orthodontia Children Molar Root 135 $ 185 Copay $ 95 Copay Copay $ 65 Copay Dental Rewards Carry Over Amount Not Available Removal of Uncomplicated PPO Bonus Not Available Single Tooth $ 100 No Charge Benefit Threshold Not Available Removal of Impacted Tooth- Max Carry Over Amt Not Available Partially Bony $ 1,000 No Charge Vision Reimbursement $ 1,000 $ 1,000 Removal of Impacted Tooth- Completely Bony $1,600 ➁ For EPO 3000, one cleaning per year. For EPO 3500, PPO 4000, PPO 5000, two cleanings per year. Adult Copay $1,600 Copay $1,950 Copay $1,950 Copay Complete Upper or Lower Denture 120 Copay $ 70 Copay Copay $ 50 Copay NOTE: Copays listed are for services performed by general dentists. Partial Upper or Lower Denture $ 110 Endodontics Orthodontia Adult Oral Surgery Orthodontics Prosthodontics (maximum age 18) -No Annual Max -No Annual Max -No Annual Max $1000 Lifetime ➄ $1000 Lifetime ➄ $1000 Lifetime ➄ Annual Maximum Not Available $ 100➆ $ 100➆ $ 100➆ ➂ Plan 3000 and 3500 claims are reimbursed at the EPO schedule for both in network and out of network. In network providers are in California only. Plan 4000 and 5000 out of network claims are reimbursed at UCR. ➃ 12 month waiting period applies. Waiting period will be waived for Groups with 10+ employees with 12 months continuous uninterrupted dental coverage on previous plan. ➄ 24 month waiting period applies. Waiting period will be waived for Groups with 10+ employees with 24 months continuous uninterrupted orthodontia coverage on previous plan. ➅ Submit one covered dental claim each year and your Basic procedures will advance to the 90% level on the following plan year and to on the third year. Physical Address (Do not use P.O. Box) Apt # City State Zip Code Home Telephone Address ( ) Mailing Address (if different from above) B. ENROLLMENT INFORMATION Complete this section ONLY if you are electing medical, dental and/or vision for yourself and dependents Employee Spouse Child Child Child Last Name Life only Please consult the EOC for specialist copays. ➀ Cost of high noble metal (gold, etc.) may be charged extra ➆ Annual Maximum per calendar year to spend at any eye care provider. File claim with Ameritas Group for reimbursement. First Name when used, not to exceed actual laboratory cost of metal. The following premiums illustrate the cost to you after your employer has made their contribution. All family members must enroll with the same Participating Plan. Your Employer has agreed to contribute: 100 % of Dental Plan 3000 for Employee Relationship to Employee Social Security No. Spouse Domestic Partner 0 % of the Dependent Rate for Same Plan as Above Have we correctly listed your Age and Residence Zip Code above? Yes No (If no, your quoted premium may be incorrect. Please notify your Health Plan Administrator.) CaliforniaChoice - Prepaid Plans THESE ARE YOUR COSTS PER MONTH. SmileSaver Employee Only Additional Cost for One Dependent Additional Cost for Two + Dependents Gender Male Female Male Female Male Female Male Female Date of Birth / / / / / / / / Disabled? Yes No Yes No Yes No Plan 3000 $ 0.00 $ $ Plan 1000 $ 9.39 $ $ CaliforniaChoice EPO/PPO Plans Enrolling For? Medical Dental Vision Medical Dental Vision Medical Dental Vision Medical Dental Vision Medical Dental Vision Ameritas Group For additional dependent enrollment, complete sections A & B on a separate application. Dependents enrolled for dental must match dependents enrolled for medical (except voluntary dental or children under Age 3). EPO 3000 $ 6.07 $ $ EPO 3500 $ $ $ PPO 4000 $ $ $ PPO 5000 $ $ $ We assume no liability for rate or benefit discrepencies. See Evidence of Coverage for complete benefits. COBRA Applicants: Indicate Qualifying Event: Please check COBRA type: Termination of employment Child no longer eligible COBRA Cal-COBRA Reduction of hours Divorce/legal separation Medicare entitlement Death of employee Date of Qualifying Event November 29, Quote PLEASE SIGN AND DATE APPLICABLE SECTIONS INSIDE APPLICATION (1 of 6) CC / Personalized Worksheet 2. Enrollment Application Look up your doctor Before you decide on which plan works best for you, visit our website to see if your doctor is in our network: Go to Click on Provider / Rx Search Type in the last name of your doctor If your doctor is not available, we make it easy for you to quickly find a new doctor in your area. Important Note: Call your doctor prior to enrolling to make sure they still participate in the health plan you have chosen. Prescription Drugs: If you or a dependent need a specific drug, you can compare health plan coverage using our online Formulary Search at While you re at check out all of the great discounts available through Cal Perks. Click HUGE DISCOUNTS for a list of discounts. 21

22 COMPLETE YOUR APPLICATION Personalized Worksheet Your Personalized Worksheet is a great tool because it shows you all of your benefit choices, and the cost associated with each option after your employer s contribution has been removed. This means what you see on your worksheet is exactly what you ll pay each pay period. You can also see the costs associated with adding a spouse and/or dependents to your coverage. Use your Personalized Worksheet to: n Compare health plan costs n Review your benefit options; choose from HMO, PPO or HSA plans n Choose your benefit level Verify your age and home Zip Code CaliforniaChoice Program EMPLOYEE ENROLLMENT WORKSHEET Effective Date: 03/01/13 SAMPLE QUOTE-RIVERSIDE All Prepaid Dental benefits are covered In-Network only. Have we correctly listed your Age and Residence Zip Code above? Yes No (If no, your quoted premium may be incorrect. Please notify your Health Plan Administrator.) We assume no liability for rate or benefit discrepencies. See Evidence of Coverage for complete benefits. EMPLOYEE #1 - Age 26 Employer Zip Code: Quote #: Residence Zip Code: Prepaid Dental Plans Plan 3000 Plan 1000 EPO/PPO Dental Plans EPO 3000➂ EPO 3500➂ PPO 4000➂ PPO 5000➂ Exams and Diagnostics In-Network EPO Network EPO Network PPO Network PPO Network $1,200 $1,600 Preventive 80%/90%/➅ Annual Deductible $ 50 Waived Ded. Waived Annual Maximum 50 $ 25 Waived $1,000 $1,000 (Max 3x/Fam) $ 25 (Max 3x/Fam) Annual Maximum Waived Ded. Initial Oral Exam No Charge Deductible No Deductible No (Max 3x/Fam) $ (Max 3x/Fam) Ded. Care Ded. Deductible No Charge Preventive➁ No Charge No Charge No Charge Annual 80%/90%/➅ Exam Basic 80% ➃ ➃ Charge No No 80%/90%/➅ Periodic Oral Cleaning Major ➃ 80% 80% Charge No Charge ➃ Endo & Periodontics ➃ 80%➃ Restorative Orthodontia Adult $ 9 Copay No Charge Cavities - Amalgam, 1 Surface $ 14 Copay No Charge Cavities - Amalgam, 2 Surfaces Orthodontia Children (maximum age 18) Crowns Out-of-Network -No Annual Max $1000 Lifetime ➄ -No Annual Max $1000 Lifetime ➄ -No Annual Max $1000 Lifetime ➄ 75 (Max 3x/Fam) $ 75 (Max 3x/Fam) Annual Ded. Deductible $ Applies 3x/Fam) $ Copay➀ $ 175 Copay➀ $ 115 Copay➀ $ 60 Copay➀ $ (Max 3x/Fam) $ 50 (Max Ded. Applies Preventive Care Ded. Waived Ded. Applies Porcelain - Base Metal (Posterior) Annual Maximum $ 600 $1,000 $1,000 $1,300 Periodontics Preventive➁ 80% 80% 80% 80% 80% Gingivectomy - Per Major ➃ Tooth Basic ➃ 80% 80% ➃ ➃ ➃ ➃ 30 Copay No Charge $ 26 $ Endo & Periodontics ➃ ➃ Copay $ 20 Copay Periodontal Scaling & Root Planing (quadrant) Endodontics Orthodontia Adult Orthodontia Children Root Canal $ 100 Copay $ 40 Copay $ 135 Copay $ 65 Copay $ 250 $ 750 Canal Dental Rewards $ 250 Bi-Root Root Canal $ 185 Copay $ 95 Copay $ 250 $ 150 Not Available $ 100 Carry Over Amount $ 100 Not Available PPO Bonus $ 500 $ 500 $ 1,000 Not Available $ 1,000 Charge Benefit Threshold Copay No $ 1,000 Not Available Max Carry Over Amt Removal of Uncomplicated Vision Reimbursement Single Tooth Removal of Impacted Tooth- $ 50 Copay No Charge Partially Bony $ 65 Copay No Charge ➁ For EPO 3000, one cleaning per year. For EPO 3500, PPO 4000, PPO 5000, two cleanings per year. Removal of Impacted Tooth- Completely Bony Oral Surgery Orthodontics $1,600 Copay $1,600 Copay Adult $1,950 Copay Children (maximum age 18) $1,950 Copay Prosthodontics Complete Upper or Lower $ 120 Copay $ 70 Copay Denture Partial Upper or Lower Denture $ 110 Copay $ 50 Copay NOTE: Copays listed are for services performed by general dentists. Please consult the EOC for specialist copays. ➀ Cost of high noble metal (gold, etc.) may be charged extra when used, not to exceed actual laboratory cost of metal. (maximum age 18) The following premiums illustrate the cost to you after your employer has made their contribution. All family members must enroll with the same Participating Plan. -No Annual Max $1000 Lifetime ➄ -No Annual Max $1000 Lifetime ➄ -No Annual Max $1000 Lifetime ➄ Annual Maximum Not Available $ 100➆ $ 100➆ $ 100➆ ➂ Plan 3000 and 3500 claims are reimbursed at the EPO schedule for both in network and out of network. In network providers are in California only. Plan 4000 and 5000 out of network claims are reimbursed at UCR. ➃ 12 month waiting period applies. Waiting period will be waived for Groups with 10+ employees with 12 months continuous uninterrupted dental coverage on previous plan. ➄ 24 month waiting period applies. Waiting period will be waived for Groups with 10+ employees with 24 months continuous uninterrupted orthodontia coverage on previous plan. ➅ Submit one covered dental claim each year and your Basic procedures will advance to the 90% level on the following plan year and to on the third year. ➆ Annual Maximum per calendar year to spend at any eye care provider. File claim with Ameritas Group for reimbursement. CaliforniaChoice - Prepaid Plans THESE ARE YOUR COSTS PER MONTH. Additional Cost SmileSaver Employee Only for One Dependent Additional Cost for Two + Dependents Plan 3000 $ 0.00 $ $ Plan 1000 $ 9.39 $ $ CaliforniaChoice EPO/PPO Plans Ameritas Group Your Employer has agreed to contribute: 100 % of Dental Plan 3000 for Employee 0 % of the Dependent Rate for Same Plan as Above EPO 3000 $ 6.07 $ $ EPO 3500 $ $ $ PPO 4000 $ $ $ PPO 5000 $ $ $ November 29, Quote Your cost for the plan of your choice appears here Your employer s contribution has already been subtracted 22 Having a birthday? Rates are guaranteed for 12 months unless your birthday moves you to a new age band Your employer s contribution appears here Add the dependent column to the Employee Only column for the total premium

23 MO DAY YEAR Social Security # required! Social Security # required! Social Security # required! Social Security # required! Steve Shorr Enrollment Application COMPLETE YOUR APPLICATION Your enrollment application will only take you a few minutes to complete. We recommend that once your application is completed that you go over it one last time to make sure all of the required fields are completed. In addition to the Employee Enrollment Application, groups with 2-14 enrolling employees must also complete the Enrollment Health Statement. Medical / Dental / Life / Vision Enrollment Application Application must be COMPLETED in FULL, SIGNED and DATED for processing. IF YOU ARE WAIVING COVERAGE, YOU MUST COMPLETE, SIGN AND DATE WAIVER ON PAGE 5 OF THIS APPLICATION. Please select one: New Hire Enrollment New Renewal Enrollment New COBRA Enrollment New Enrollment/Qualifying Event A. PERSONAL INFORMATION Name of Company Employer Phone # Employee Job Title Full-time Employment Date Select Marital Status Sex M F Status Married Single (Note: If you or any of your dependents are not enrolling, you must also complete and sign the waiver section on page 5.) Domestic Partner Employee Last Name Employee Social Security Number Employee First Name Middle Initial Date of Birth Group Number Physical Address (Do not use P.O. Box) Apt # City State Zip Code Include Social Security Numbers for dependents Home Telephone ( ) Address Mailing Address (if different from above) B. ENROLLMENT INFORMATION Complete this section ONLY if you are electing medical, dental and/or vision for yourself and dependents Include date of hire Last Name First Name Relationship to Employee Social Security No. Employee Spouse Child Child Child Life only Spouse Domestic Partner Gender Male Female Male Female Male Female Male Female Date of Birth / / / / / / / / Disabled? Yes No Yes No Yes No Enrolling For? Medical Dental Vision Medical Dental Vision Medical Dental Vision Medical Dental Vision Medical Dental Vision For additional dependent enrollment, complete sections A & B on a separate application. Dependents enrolled for dental must match dependents enrolled for medical (except voluntary dental or children under Age 3). COBRA Applicants: Please check COBRA type: COBRA Cal-COBRA Indicate Qualifying Event: Termination of employment Child no longer eligible Reduction of hours Divorce/legal separation Medicare entitlement Death of employee Date of Qualifying Event PLEASE SIGN AND DATE APPLICABLE SECTIONS INSIDE APPLICATION (1 of 6) CC /2012 Frequently missed sections: Children s SSN Disabled dependent box Doctor s ID Number Current Patient (if HMO) Dentist chosen (if DMO) Life beneficiary (if Life Insurance offered) Date of hire Marital status Sign Your Application Sign here if you are accepting coverage 23