2015 ADJUNCT MEDICAL BENEFITS PROGRAM MEDICAL PLANS

Transcription

1 2015 ADJUNCT MEDICAL BENEFITS PROGRAM MEDICAL PLANS

2 SISC BLUE SHIELD OF CALIFORNIA HEALTH PLANS SISC BLUE SHIELD OF CALIFORNIA PPO HEALTH PLAN SISC BLUE SHIELD OF CALIFORNIA HMO HEALTH PLAN SISC BLUE SHIELD OF CALIFORNIA ACCOUNT BASED HEALTH PLAN (ABHP) ELIGIBLE FOR PARTICIPATION IN A HEALTH SAVINGS ACCOUNT (HSA)

3 SISC ASO Blue Shield of California 100% Plan A $30 Copayment Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Blue Shield of California Effective: October 1, 2015 Calendar Year Medical Deductible (All providers combined) Calendar Year Out-of-Pocket Maximum 2 (Includes the plan deductible) LIFETIME BENEFIT MAXIMUM Participating Providers 1 Non Participating Providers 1 None $1,000 per individual / $3,000 per family None Covered Services Member Copayment PROFESSIONAL SERVICES Participating Providers 1 Non Participating Providers 1 Professional (Physician) Benefits Physician and specialist office visits $30 per visit 50% 2 CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic No Charge 50% 2 procedures utilizing nuclear medicine (prior authorization is required) 3 Other outpatient X-ray, pathology and laboratory (Diagnostic testing by No Charge Not Covered providers other than outpatient laboratory, pathology, and imaging departments of 3 hospitals/facilities) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) No Charge 50% 2 Preventive Health Benefits Preventive Health Services (As required by applicable federal law.) No Charge Not Covered OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery Center 4 No Charge No Charge 5 Outpatient surgery in a hospital No Charge No Charge 5 Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under "Rehabilitation Benefits") No Charge 50% 2 CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital (prior No Charge 50% 2, 5 3 authorization is required) Other outpatient X-ray, pathology and laboratory performed in a hospital 3 Bariatric Surgery (prior authorization required by the Plan; medically necessary 6 surgery for weight loss, for morbid obesity only) HOSPITALIZATION SERVICES No Charge Not Covered No Charge No Charge 5 Hospital Benefits (Facility Services) Inpatient Physician Services No Charge 2, 15 50% Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care) No Charge No Charge 7 Bariatric Surgery (prior authorization required by the Plan; medically necessary No Charge No Charge 7 6 surgery for weight loss, for morbid obesity only) Skilled Nursing Facility Benefits 8 (Combined maximum of up to 100 prior authorized days per Calendar Year; semi-private accommodations) Services by a free-standing Skilled Nursing Facility No Charge No Charge 9 Skilled Nursing Unit of a Hospital No Charge No Charge 7 EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission (The ER $100 per visit $100 per visit copayment does not apply if the member is directly admitted to the hospital for inpatient services) Emergency room Services resulting in admission (when the member is No Charge No Charge admitted directly from the ER) Emergency room Physician Services No Charge No Charge 15 An independent member of the Blue Shield Association

4 AMBULANCE SERVICES Emergency or authorized transport No Charge No Charge PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits Administered by Navitus Health Solutions PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (Separate office visit copay may apply) No Charge 50% 2 Orthotic equipment and devices (Separate office visit copay may apply) No Charge Not Covered DURABLE MEDICAL EQUIPMENT Breast pump No Charge Not Covered Other Durable Medical Equipment No Charge Not Covered 10, 11 MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES Inpatient Hospital Services No Charge No Charge 7 Residential Care No Charge No Charge 7 Inpatient Physician Services No Charge 2, 15 50% Routine Outpatient Mental Health and Substance Abuse Services (includes professional/physician visits) Non-Routine Outpatient Mental Health and Substance Abuse Services (includes behavioral health treatment, electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization programs, and transcranial magnetic stimulation. For partial hospitalization programs, a higher copayment and facility charges may apply per episode of care) HOME HEALTH SERVICES $30 per visit 50% 2 No Charge 50% 2 Home health care agency Services (up to 100 visits per Calendar Year) 8 No Charge Not Covered 12 Home infusion/home intravenous injectable therapy and infusion No Charge Not Covered 12 nursing visits provided by a Home Infusion Agency OTHER Hospice Program Benefits Routine home care No Charge Not Covered 12 Inpatient Respite Care No Charge Not Covered hour Continuous Home Care No Charge Not Covered 12 General Inpatient care No Charge Not Covered 12 Chiropractic Benefits 8 Chiropractic Services (up to 20 visits per Calendar Year) No Charge Not Covered Acupuncture Benefits 8 Acupuncture Services (up to 12 visits per Calendar Year) No Charge 50% 2 Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Office location No Charge Not Covered Speech Therapy Benefits Office Visit No Charge 50% 2 Pregnancy and Maternity Care Benefits Prenatal and postnatal Physician office visits (For inpatient hospital services, see "Hospitalization Services") Abortion services (Facility charges may apply - see "Hospital Benefits (Facility Services)") Family Planning Benefits $30 per visit 50% 2 No Charge Not Covered Counseling and consulting 13 No Charge Not Covered Tubal ligation No Charge Not Covered Vasectomy 14 No Charge Not Covered Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see Outpatient Prescription Drug Benefits.) No Charge 50% 2 Diabetes self-management training $30 per visit 50% 2 Hearing Aid Benefits Audiological evaluations $30 per visit 50% 2 Hearing Aid Instrument and ancillary equipment (Up to a maximum combined benefit of $700 per person every 24 months for the hearing aid and ancillary equipment) No Charge No Charge Care Outside of Plan Service Area Benefits provided through BlueCard Program, for out-of-state emergency and non-emergency care, are provided at the Participating level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider. Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit

5 1 Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. Participating providers agree to accept Blue Shield's allowable amount plus the plan s and any applicable member s payment as full payment for covered services. Non Participating providers can charge more than these amounts. When members use Non Participating providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the Calendar Year deductible or out-of-pocket maximum. 2 Copayments/Coinsurance marked with this footnote do not accrue to Calendar Year out-of-pocket maximum. Copayments/Coinsurance and charges for services not accruing to the member's Calendar Year out-of-pocket maximum continue to be the member's responsibility after the Calendar Year out-of-pocket maximum is reached. This amount could be substantial. Please refer to the Plan Contract for exact terms and conditions of coverage. 3 Participating non Hospital based ("freestanding") laboratory or radiology centers may not be available in all areas. Laboratory and radiology Services may also be obtained from a Hospital or from a laboratory and radiology center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 4 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 5 The maximum allowed charges for non-emergency surgery performed in a Non Participating Ambulatory Surgery Center or outpatient unit of a Non Participating hospital is $350 per day. Members are responsible for all charges in excess of $ Bariatric surgery is covered when pre-authorized by the Plan. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other Participating provider and there is no coverage for bariatric services from Non Participating providers. In addition, if prior authorized by the Plan, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Plan Contract for further benefit details. 7 The maximum allowed charges for non-emergency hospital services received from a Non Participating hospital is $600 per day. Members are responsible for all charges in excess of $ For plans with a Calendar Year medical deductible amount, services with a day or visit limit accrue to the Calendar Year day or visit limit maximum regardless of whether the plan medical deductible has been met. 9 Services may require prior authorization by the Plan. When services are prior authorized, members pay the Participating provider amount. 10 Mental health and Substance Abuse services are accessed through Blue Shield s Participating and Non Participating providers. 11 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Plan Contract for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's Participating providers or with Non Participating providers. 12 Out of network home health care, home infusion and hospice services are not covered unless pre-authorized. When these services are pre-authorized, the member pays the Participating provider copayment. 13 Includes insertion of IUD, as well as injectable and implantable contraceptives for women. 14 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Services from Non Participating providers and Non Participating facilities are not covered under this benefit. 15 When these services are rendered by a Non Participating Radiologist, Anesthesiologist, Pathologist and Emergency Room Physicians in a Participating facility, the member pays the Participating Provider copayment. Plan designs may be modified to ensure compliance with federal requirements. ASO (1/15) RH ; DC ; ;

6 Self-Insured Schools of California (SISC) Pharmacy Benefit Schedule PLAN Walk-in 200DED/10-35 Mail Network Costco Costco Navitus Days Supply* Generic $10 Free Free Free Brand $35 $35 $90 $90 Specialty $35 Out-of-Pocket Maximum Brand/Specialty Deductible $2,500 Individual / $3,500 Family $200 Individual / $500 Family SISC urges members to use generic drugs when available. If you or your physician requests the brand name when a generic equivalent is available, you will pay the generic copay plus the difference in cost between the brand and generic. The difference in cost between the brand and generic will not count toward the Annual Out-of-Pocket Maximum. *Members may receive up to 30 days and/or up to 90 days supply of medication at participating pharmacies. Some narcotic pain and cough medications are not included in the Costco Free Generic or 90-day supply programs. Navitus contracts with most independent and chain pharmacies with the exception of Walgreens. Mail Order Service The Mail Order Service allows you to receive a 90-day supply of maintenance medications. This program is part of your pharmacy benefit and is voluntary. Specialty Pharmacy Navitus SpecialtyRx helps members who are taking medications for certain chronic illnesses or complex diseases by providing services that offer convenience and support. This program is part of your pharmacy benefit and is mandatory. Navi-Gate for Members allows you to access personalized pharmacy benefit information online at For information specific to your plan, visit Navi-Gate for Members. Activate your account online using the Member Login link and an activation will be sent to you. The site provides access to prescription benefits, pharmacy locator, drug search, drug interaction information, medication history, and mail order information. The site is available 24 hours a day, seven days a week. 2015_2016_RX_10_35_200_500_DED Navitus SISC 14

7 SISC Custom HMO Admit Inpatient Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Highlights: A description of the prescription drug coverage is provided separately THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Effective: October 1, 2015 Calendar Year Medical Deductible None Calendar Year Out-of-Pocket Maximum $2,000 per Individual / $4,000 per Family LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $25 per visit (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services) Outpatient X-ray, pathology and laboratory No Charge Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $25 per visit Access+ Specialist SM Benefits 1 Office visit, Examination or Other Consultation (Self-referred office visits and consultations only) $30 per visit Preventive Health Benefits Preventive Health Services (As required by applicable federal and California law.) No Charge OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery Center 2 $150 per surgery Outpatient surgery in a hospital $300 per surgery Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits") No Charge HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient Physician Services No Charge Inpatient Non-emergency Facility Services (Semi-private room and board, and medically $500 per admission necessary Services and supplies, including Subacute Care) Inpatient Medically Necessary skilled nursing Services including Subacute Care 3, 4 $100 per day EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission (The ER copayment does not apply if $100 per visit the member is directly admitted to the hospital for inpatient services) Emergency room Physician Services No Charge AMBULANCE SERVICES Emergency or authorized transport $100 PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits Administered by Navitus Health Solutions PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (Separate office visit copay may apply) No Charge Orthotic equipment and devices (Separate office visit copay may apply) No Charge DURABLE MEDICAL EQUIPMENT Breast pump No Charge Other Durable Medical Equipment (member share is based upon allowed charges) 20% An independent member of the Blue Shield Association

8 MENTAL HEALTH AND SUBSTANCE SERVICES 5, 6 Inpatient Hospital Services $500 per admission Residential Care $500 per admission Inpatient Physician Services No Charge Routine Outpatient Mental Health and Substance Abuse Services (includes professional/physician visits) Non-Routine Outpatient Mental Health and Substance Abuse Services (includes behavioral health treatment, electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization programs and transcranial magnetic stimulation. For partial hospitalization programs, a higher copayment and facility charges may apply per episode of care) HOME HEALTH SERVICES Home health care agency Services (up to 100 visits per Calendar Year) $25 per visit Medical supplies (See "Prescription Drug Coverage" for specialty drugs) No Charge Urgent Care Benefits (BlueCar d Program) $25 per visit No Charge OTHER Hospice Program Benefits Routine home care No Charge Inpatient Respite Care No Charge 24-hour Continuous Home Care $250 per day General Inpatient care $250 per day Pregnancy and Maternity Care Benefits Prenatal and postnatal Physician office visits (For inpatient hospital services, see No Charge "Hospitalization Services") Abortion services 8 $100 per surgery Family Planning and Infertility Benefits Counseling and consulting 7 No Charge Infertility Services (member share is based upon allowed charges) 50% (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT). Tubal ligation No Charge Vasectomy 8 $75 per surgery Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Office location (Copayment applies to all places of services, including professional and facility settings) $25 per visit Speech Therapy Benefits Office Visit (Copayment applies to all places of services, including professional and facility settings) $25 per visit Diabetes Care Benefits Devices, equipment, and non-testing supplies (member share is based upon allowed charges; 20% for testing supplies see Outpatient Prescription Drug Benefits.) Diabetes self-management training $25 per visit Hearing Aids Audiological evaluations $25 per visit Hearing Aid Instrument and ancillary equipment (every 24 months for the hearing aid and ancillary equipment) Urgent Services outside your Personal Physician Service Area $25 per visit Optional Benefits Optional dental, vision, hearing aid, infertility, chiropractic or chiropractic and acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. 1 To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by a MHSA network Participating provider. 2 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 3 For Plans with a facility deductible amount, services with a day or visit limit accrue to the Calendar Year day or visit limit maximum regardless of whether the plan deductible has been met. 4 Skilled nursing services are limited to 100 preauthorized days during a calendar year except when received through a hospice program provided by a Participating hospice agency. This 100 preauthorized day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 5 Mental Health and Substance Abuse services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA Participating providers. 6 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield Participating providers. 7 Includes insertion of IUD, as well as injectable and implantable contraceptives for women. 8 Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Plan designs may be modified to ensure compliance with state and federal requirements. A15814 (1/15) RH ; %

9 Chiropractic and Acupuncture Benefits Additional coverage for your HMO and POS plans Blue Shield Chiropractic and Acupuncture Care coverage lets you self-refer to a network of more than 3,310 licensed chiropractors and more than 1,245 licensed acupuncturists. Benefits are provided through a contract with American Specialty Health Plans of California, Inc. (ASH Plans). How the Program Works You can visit any participating chiropractors or acupuncturists in California from the ASH Plans network without a referral from your HMO or POS Personal Physician. Simply call a participating provider to schedule an initial exam. At the time of your first visit, you ll present your Blue Shield identification card and pay only your copayment. Because participating chiropractors and acupuncturists bill ASH Plans directly, you ll never have to file claim forms. If you need further treatment, the participating chiropractor or acupuncturist will submit a proposed treatment plan to ASH Plans and obtain the necessary authorization from ASH Plans to continue treatment up to the calendar-year maximum of 30 combined visits. What s Covered The plan covers medically necessary chiropractic and acupuncture services including: Initial and subsequent examinations Office visits and adjustments (subject to annual limits) Adjunctive therapies X-rays (chiropractic only) Benefit Plan Design Calendar-year Maximum 30 Combined Visits Calendar-year Deductible Calendar-year Chiropractic Appliances Benefit 1,2 $50 Covered Services Acupuncture Services Chiropractic Services Out-of-network Coverage 1. Chiropractic appliances are covered up to a maximum of $50 in a calendar-year as authorized by ASH Plans. None Member Copayment $10 per visit $10 per visit 2. As authorized by ASH Plans, this allowance is applied toward the purchase of items determined necessary, such as supports, collars, pillows, heel lifts, ice packs, cushions, orthotics, rib belts and home traction units. Friendly Customer Service Helpful ASH Plans Member Services representatives are available at (800) Monday through Friday from 6 a.m. to 5 p.m. to answer questions, assist with problems, or help locate a participating chiropractor or acupuncturist. This document is only a summary for informational purposes. It is not a contract. Please refer to the Evidence of Coverage and the Group Health Service Agreement for the exact terms and conditions of coverage. None An independent member of the Blue Shield Association A17273 (01/15

10 Self-Insured Schools of California (SISC) Pharmacy Benefit Schedule PLAN Walk-in 200DED/10-35 Mail Network Costco Costco Navitus Days Supply* Generic $10 Free Free Free Brand $35 $35 $90 $90 Specialty $35 Out-of-Pocket Maximum Brand/Specialty Deductible $2,500 Individual / $3,500 Family $200 Individual / $500 Family SISC urges members to use generic drugs when available. If you or your physician requests the brand name when a generic equivalent is available, you will pay the generic copay plus the difference in cost between the brand and generic. The difference in cost between the brand and generic will not count toward the Annual Out-of-Pocket Maximum. *Members may receive up to 30 days and/or up to 90 days supply of medication at participating pharmacies. Some narcotic pain and cough medications are not included in the Costco Free Generic or 90-day supply programs. Navitus contracts with most independent and chain pharmacies with the exception of Walgreens. Mail Order Service The Mail Order Service allows you to receive a 90-day supply of maintenance medications. This program is part of your pharmacy benefit and is voluntary. Specialty Pharmacy Navitus SpecialtyRx helps members who are taking medications for certain chronic illnesses or complex diseases by providing services that offer convenience and support. This program is part of your pharmacy benefit and is mandatory. Navi-Gate for Members allows you to access personalized pharmacy benefit information online at For information specific to your plan, visit Navi-Gate for Members. Activate your account online using the Member Login link and an activation will be sent to you. The site provides access to prescription benefits, pharmacy locator, drug search, drug interaction information, medication history, and mail order information. The site is available 24 hours a day, seven days a week. 2015_2016_RX_10_35_200_500_DED Navitus SISC 14

11 SISC ASO PPO HSA Plan A Benefit Summary Blue Shield of California Highlights: $1,500 individual coverage deductible or $3,000 family coverage deductible THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Effective: October 1, 2015 Participating Providers 1 Non Participating Providers 1 Calendar Year Deductible (All providers combined) $1,500 per Individual / $3,000 per Family (Note: For individual on family coverage plan, enrollee can receive benefits for covered services once individual deductible is met.) Calendar Year Out-of-Pocket Maximum 2 (Includes the plan deductible) $4,000 per Individual / $8,000 per Family (For individual on family coverage plan, enrollee can receive 100% benefits for covered services once individual out-of-pocket maximum is met.) LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Participating Providers 1 Non Participating Providers 1 Professional (Physician) Benefits Physician and specialist office visits 10% 50% 2 CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required) 3 10% 50% 2 Other outpatient X-ray, pathology and laboratory (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of 10% Not Covered 3 hospitals/facilities) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 10% 50% 2 Preventive Health Benefits Preventive Health Services (As required by applicable federal law.) No Charge Not Covered OUTPATIENT SERVICES (Not subject to the Calendar Year Deductible) Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery Center 4 10% No Charge 5 Outpatient surgery in a hospital 10% No Charge 5 Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under "Rehabilitation Benefits") 10% 50% 2 CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital (prior 10% 50% 2, 5 3 authorization is required) Other outpatient X-ray, pathology and laboratory performed in a hospital 3 Bariatric Surgery (prior authorization required by the Plan; medically necessary 6 surgery for weight loss, for morbid obesity only) 10% Not Covered 10% No Charge 5 HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient Physician Services 10% 2, 10 50% Inpatient Non-emergency Facility Services (Semi-private room and board, and medically necessary Services and supplies, including Subacute Care) 10% No Charge 7 Bariatric Surgery (prior authorization required by the Plan; medically necessary 10% No Charge 7 6 surgery for weight loss, for morbid obesity only) Skilled Nursing Facility Benefits 8 (Combined maximum of up to 100 days per Calendar Year; semi-private accommodations) Services by a free-standing Skilled Nursing Facility 10% 10% 9 Skilled Nursing Unit of a Hospital 10% No Charge 7 EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission (The ER $100 per visit + 10% $100 per visit + 10% copayment does not apply if the member is directly admitted to the hospital for inpatient services) Emergency room Services resulting in admission (when the member is 10% 10% admitted directly from the ER) Emergency room Physician Services 10% 10% 11 An independent member of the Blue Shield Association

12 AMBULANCE SERVICES Emergency or authorized transport 10% 10% 11, 12, 13, 14, 15 PRESCRIPTION DRUG COVERAGE Participating Pharmacy Non Participating Pharmacy (Subject to deductible) Outpatient Prescription Drug Benefits Retail Prescriptions (For up to a 30-day supply) Contraceptive Drugs and Devices 16 No Charge Not Covered Formulary Generic Drugs $7 per prescription $7 per prescription Formulary Brand Name Drugs $25 per prescription $25 per prescription Non-Formulary Brand Name Drugs $25 per prescription $25 per prescription Mail Service Prescriptions (For up to a 90-day supply) Contraceptive Drugs and Devices 16 No Charge Not Covered Formulary Generic Drugs $14 per prescription Not Covered Formulary Brand Name Drugs $60 per prescription Not Covered Non-Formulary Brand Name Drugs $60 per prescription Not Covered Specialty Pharmacies (up to a 30-day supply) Specialty Drugs $25 per prescription Not Covered PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (Separate office visit copay may apply) 10% 50% 2 Orthotic equipment and devices (Separate office visit copay may apply) 10% Not Covered DURABLE MEDICAL EQUIPMENT Breast pump No Charge Not Covered (Not subject to the Calendar Year Deductible) Other Durable Medical Equipment 10% Not Covered MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 17, 18 Inpatient Hospital Services 10% No Charge 7 Residential Care 10% No Charge 7 Inpatient Physician Services 10% 50% 2 Routine Outpatient Mental Health and Substance Abuse Services (includes professional/physician visits) Non-Routine Outpatient Mental Health and Substance Abuse Services (includes behavioral health treatment, electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization programs, and transcranial magnetic stimulation. For partial hospitalization programs, a higher copayment and facility charges may apply per episode of care) HOME HEALTH SERVICES 10% 50% 2 10% 50% 2 Home health care agency Services (up to 100 visits per Calendar Year) 8 10% Not Covered 19 Home infusion/home intravenous injectable therapy and infusion 10% Not Covered 19 nursing visits provided by a Home Infusion Agency OTHER Hospice Program Benefits Routine home care 10% Not Covered 19 Inpatient Respite Care 10% Not Covered hour Continuous Home Care 10% Not Covered 19 General Inpatient care 10% Not Covered 19 Chiropractic Benefits 8 Chiropractic Services (up to 20 visits per Calendar Year) 10% Not Covered Acupuncture Benefits 8 Acupuncture Services (up to 12 visits per Calendar Year) 10% 50% 2 Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Office location 10% Not Covered Speech Therapy Benefits Office Visit 10% 50% 2 Pregnancy and Maternity Care Benefits Prenatal and postnatal Physician office visits (For inpatient hospital services, see "Hospitalization Services") Abortion services (Facility charges may apply - see "Hospital Benefits (Facility Services)") 10% 50% 2 10% Not Covered

13 Family Planning Benefits Counseling and consulting 20 No Charge (Not subject to the Calendar Year Deductible) Not Covered Tubal ligation No Charge Not Covered (Not subject to the Calendar Year Deductible) Vasectomy 21 10% Not Covered Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see Outpatient Prescription Drug Benefits.) 10% 50% 2 Diabetes self-management training 10% 50% 2 Hearing Aid Benefits Audiological evaluations 10% 50% 2 Hearing Aid Instrument and ancillary equipment (Up to a maximum combined benefit of $700 per person every 24 months for the hearing aid and ancillary equipment) 10% 10% Care Outside of Plan Service Area (Benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the Participating level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit 1 Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. Participating providers agree to accept Blue Shield's allowable amount plus the plan s and any applicable member s payment as full payment for covered services. Non Participating providers can charge more than these amounts. When members use Non Participating providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield's allowable amount. Charges in excess of the allowable amount do not count toward the Calendar Year deductible or out-of-pocket maximum. Payments applied to your Calendar Year deductible accrue towards the out-of-pocket maximum. 2 Copayments/Coinsurance marked with this footnote does not accrue to Calendar Year out-of pocket maximum. Copayments/Coinsurance and charges for services not accruing to the member's Calendar Year out-of-pocket maximum continue to be the member's responsibility after the Calendar Year out-of-pocket maximum is reached. This amount could be substantial. Please refer to the Plan Contract for exact terms and conditions of coverage. 3 Participating non Hospital based ("freestanding") laboratory or radiology centers may not be available in all areas. Laboratory and radiology Services may also be obtained from a Hospital or from a laboratory and radiology center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 4 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 5 The maximum allowed charges for non-emergency surgery performed in a Non Participating Ambulatory Surgery Center or outpatient unit of a Non Participating hospital is $350 per day. Members are responsible for all charges in excess of $ Bariatric surgery is covered when pre-authorized by the Plan. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other Participating provider and there is no coverage for bariatric services from Non Participating providers. In addition, if prior authorized by the Plan, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Plan Contract for further benefit details. 7 The maximum allowed charge for non-emergency hospital services received from a Non Participating hospital is $600 per day. Members are responsible for all charges in excess of $600. Payments that exceed the allowed charge do not count toward the Calendar Year out-of-pocket maximum, and continue to be owed after the maximum is reached. 8 For plans with a Calendar Year deductible amount, services with a day or visit limit accrue to the Calendar Year day or visit limit maximum regardless of whether the plan deductible has been met. 9 Services may require prior authorization by the Plan. When services are prior authorized, members pay the Participating provider amount. 10 W hen these services are rendered by a Non Participating Radiologist, Anesthesiologist, Pathologist and Emergency Room Physicians in a Participating facility, the member pays the Participating Provider copayment. 11 If the member requests a Brand Name drug when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the Brand Name Drug and its generic drug equivalent, as well as the applicable generic drug Copayment. This difference in cost that the member must pay is not applied to their Calendar Year deductible and is not included in the Calendar Year out-of-pocket maximum responsibility calculations. 12 Please note that if you switch from another plan, your prescription drug deductible credit from the previous plan during the Calendar Year, if applicable, will not carry forward to your new plan. 13 For the Outpatient Prescription Drugs Benefit, covered Drugs obtained from Non Participating Pharmacies will be subject to and accrue to the Calendar Year Deductible and the Calendar Year Out-of-Pocket Maximum for Participating providers. 14 Specialty drugs are covered only when dispensed by select pharmacies in the Specialty Pharmacy Network unless Medically Necessary for a covered emergency. 15 Specialty Drugs are specific Drugs used to treat complex or chronic conditions which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the patient or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy and may require prior authorization for Medical Necessity by Blue Shield. Infused or Intravenous (IV) medications are not included as Specialty Drugs. 16 Contraceptive Drugs and Devices covered under the outpatient prescription drug benefits will not be subject to the Calendar Year deductible. If a Brand Name contraceptive is requested when a generic equivalent is available, the member will be responsible for paying the difference between the cost to Blue Shield for the Brand Name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be covered without a copayment. 17 Mental Health and Substance Abuse services are accessed through Blue Shield s Participating and Non Participating providers. 18 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Plan Contract for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's Participating providers or with Non Participating providers. 19 Out of network home health care, home infusion and hospice services are not covered unless pre-authorized. When these services are pre-authorized, the member pays the Participating provider Copayment. 20 Includes insertion of IUD, as well as injectable and implantable contraceptives for women. 21 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Services from Non Participating providers and Non Participating facilities are not covered under this benefit. Plan designs may be modified to ensure compliance with federal requirements. ASO (1/15) DC ; ; ;

14 SISC KAISER PERMANENTE HEALTH PLANS SISC KAISER PERMANENTE HMO HEALTH PLAN SISC KAISER PERMANENTE ACCOUNT BASED HEALTH PLAN (ABHP) ELIGIBLE FOR PARTICIPATION IN A HEALTH SAVINGS ACCOUNT (HSA)

15 Benefit Summary SISC - SELF-INSURED SCHOOLS OF CALIFORNIA Principal Benefits for Kaiser Permanente Traditional Plan (10/1/15 9/30/16) The Services described below are covered only if all of the following conditions are satisfied: The Services are Medically Necessary The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Northern California Region Service Area (your Home Region), except where specifically noted to the contr ary in the Evidence of Coverage (EOC) for authorized referrals, hospice care, Emergency Services, Post-Stabilization Care, Out-of- Area Urgent Care, and emergency ambulance Services Accumulation Period The Accumulation Period for this plan is 1/1/15 through 12/31/15 (calendar year). Plan Out-of-Pocket Maximum For Services subject to the maximum, you will not pay any more Cost Share for the rest of the calendar year if the Copayments and Coinsurance you pay for those Services add up to one of the following amounts: For self-only enrollment (a Family of one Member)... $1,500 per calendar year For any one Member in a Family of two or more Members... $1,500 per calendar year For an entire Family of two or more Members... $3,000 per calendar year Plan Deductible None Professional Services (Plan Provider office visits) Most Primary Care Visits for evaluations and treatment... $25 per visit Most Specialty Care Visits for consultations, evaluations, and treatment... $25 per visit Routine physical maintenance exams, including well-woman exams... No charge Well-child preventive exams (through age 23 months)... No charge Family planning counseling and consultations... No charge Scheduled prenatal care exams... No charge Routine eye exams with a Plan Optometrist... No charge Hearing exams... No charge Urgent care consultations, evaluations, and treatment... $25 per visit Most physical, occupational, and speech therapy... $25 per visit Outpatient Services Outpatient surgery and certain other outpatient procedures... $25 per procedure Allergy injections (including allergy serum)... $5 per visit Most immunizations (including the vaccine)... No charge Most X-rays and laboratory tests... No charge Covered individual health education counseling... No charge Covered health education programs... No charge Hospitalization Services Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs... No charge Emergency Health Coverage Emergency Department visits... $100 per visit Note: This Cost Share does not apply if admitted directly to the hospital as an inpatient for covered Services (see "Hospitalization Services" for inpatient Cost Share). Ambulance Services Ambulance Services... $50 per trip Prescription Drug Coverage Covered outpatient items in accord with our drug formulary guidelines at a Plan Pharmacy or through our mail-order service: Most generic items... $10 for up to a 100-day supply Most brand-name items... $25 for up to a 100-day supply Durable Medical Equipment (DME) DME items that are essential health benefits in accord with our DME formulary guidelines... No charge DME items that are not essential health benefits in accord with our DME formulary guidelines... No charge S SISC - Self-Insured Schools Of California (continues)

16 Benefit Summary Mental Health Services Inpatient psychiatric hospitalization... No charge Individual outpatient mental health evaluation and treatment... $25 per visit Group outpatient mental health treatment... $12 per visit Chemical Dependency Services Inpatient detoxification... No charge Individual outpatient chemical dependency evaluation and treatment... $25 per visit Group outpatient chemical dependency treatment... $5 per visit Home Health Services Home health care (up to 100 visits per calendar year)... No charge Other Skilled nursing facility care (up to 100 days per benefit period)... No charge Prosthetic and orthotic devices... No charge All Services related to covered infertility treatment... 50% Coinsur ance Hospice care... No charge (continued) This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies) S SISC - Self-Insured Schools Of California S

17 Provided by American Specialty Health Plans of California, Inc. (ASH Plans) Your Kaiser Permanente CHIROPRACTIC and ACUPUNCTURE benefits When you need chiropractic or acupuncture care, follow these simple steps: 1. Find an ASH Plans Participating Chiropractor or Participating Acupuncturist near you. Call or 711 (TTY), weekdays from 5 a.m. to 6 p.m. (Pacific time) Schedule an appointment. Pay for your office visit when you arrive for your appointment. (See the reverse for more details.)

18 YOUR KAISER PERMANENTE COMBINED CHIROPRACTIC AND ACUPUNCTURE BENEFIT Services Chiropractic Services are covered when a Participating Chiropractor finds that the Services are Medically Necessary to treat or diagnose Neuromusculoskeletal Disorders. Acupuncture Services are covered when a Participating Acupuncturist finds that the Services are Medically Necessary to treat or diagnose Neuromusculoskeletal Disorders, nausea, or pain. You can obtain Services from any ASH Plans Participating Chiropractors and Participating Acupuncturists without a referral from a Kaiser Permanente Plan Physician. Cost Sharing and Office Visit Maximums Office visit cost share: $10 copay per visit Office visit limit: Up to a combined total of 30 Chiropractic and Acupuncture visits per year Chiropractic appliance benefit: If the amount of the appliance in the ASH Plans fee schedule exceeds $50, you will pay the amount in excess of $50, and that payment will not apply toward any applicable deductible or out-of-pocket maximum. Covered chiropractic appliances are limited to: elbow supports, back supports, cervical collars, cervical pillows, heel lifts, hot or cold packs, lumbar braces and supports, lumbar cushions, orthotics, wrist supports, rib belts, home traction units, ankles braces, knee braces, rib supports, and wrist braces. Office visits: Covered Services are limited to Medically Necessary Chiropractic and Acupuncture Services authorized and provided by ASH Plans Participating Chiropractors and Participating Acupuncturists except for Emergency Chiropractic and Acupuncture Services, and Services that are not available from Participating Providers. Each office visit counts toward the year visit limit even if acupuncture or a chiropractic adjustment is not provided during the visit. X-rays and laboratory tests: Medically Necessary X-rays and laboratory tests are covered at no charge when a Participating Chiropractor provides the Services or refers you to a Participating Provider for the Services. Participating Chiropractors and Acupuncturists ASH Plans contracts with Participating Chiropractors and other Participating Providers to provide covered Chiropractic Services (including laboratory tests, X-rays, and chiropractic appliances). ASH Plans contracts with Participating Acupuncturists to provide acupuncture care (including adjunctive therapies, such as acupressure, cupping, moxibustion, or breathing techniques, when provided during the same course of treatment and in conjunction with acupuncture). You must receive covered Services from a Participating Provider, except for Emergency Chiropractic and Acupuncture Services, Urgent Chiropractic and Acupuncture Services, and Services that are not available from Participating Providers that are authorized in advance by ASH Plans. The list of Participating Chiropractors and Acupuncturists is available from the ASH Plans Member Services Department at The list of Participating Chiropractors and Acupuncturists is subject to change at any time without notice. How to Obtain Covered Services To obtain covered Services, call a Participating Chiropractor or Participating Acupuncturist to schedule an initial examination. If additional Services are required, verification that the Services are Medically Necessary may be required. Your Participating Chiropractor or Acupuncturist will request any required approvals. An ASH Plan s clinician in the same or similar specialty as the provider of Chriopractic or Acupuncture Services under review will decide whether Chiropractic or Acupuncture Servies are or were Medically Necessary. ASH Plans will disclose to you, upon request, the written criteria it uses to make the decision to authorize, modify, delay, or deny a request for authorization. If you have questions or concerns, please contact the ASH Plans Member Services Department. Second Opinions You may request a second opinion in regard to covered Services by contacting another Participating Chiropractor or Acupuncturist. A Participating Chiropractor or Acupuncturist may also request a second opinion in regard to covered Services by referring you to another Participating Chiropractor or Acupuncturist in the same or similar specialty. Your Costs When you receive covered Services, you must pay your Cost Share as described in the Combined Chiropractic and Acupuncture Services Amendment of your Health Plan Evidence of Coverage. The Cost Share does not apply toward the out-of-pocket maximum described in the Health Plan Evidence of Coverage (unless you have a plan with an HSA option). Emergency and Urgent Chiropractic Services/Emergency and Urgent Acupuncture Services Covered Emergency Chiropractic Services are those emergency services provided for treatment of Neuromusculoskeletal Disorder, nausea, or pain. Covered Acupuncture Services are those emergency services provided for treatment of Neuromusculoskeletal Disorder, nausea, or pain. These conditions must manifest themselves by acute symptoms of sufficient severity, including severe pain, such that a reasonable person could expect the absence of immediate Chiropractic or Acupuncture Services to result in serious jeopardy to your health or body functions or organs. Covered Urgent Chiropractic Services and Acupuncture Services consist of Chiropractic Services and Acupuncture Services necessary to prevent serious deterioration of the health of a Member, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the Member returns to the Service Area. Getting Assistance If you have questions about the Services you can get from an ASH Plans Participating Provider, you may call ASH Plans Member Services at (TTY users call 711), weekdays from 5 a.m. to 6 p.m. Pacific time.

19 YOUR KAISER PERMANENTE COMBINED CHIROPRACTIC AND ACUPUNCTURE BENEFIT Grievances You can file a grievance with Kaiser Permanente regarding any issue. Your grievance must explain your issue, such as the reasons why you believe a decision was in error or why you are dissatisfied with Services you received. You may submit your grievance orally or in writing to Kaiser Permanente as described in your Health Plan Evidence of Coverage. Exclusions and Limitations Acupuncture Services for conditions other than Neuromusculoskeletal Disorders, nausea, and pain Services for asthma or addiction, such as nicotine addiction Hypnotherapy, behavior training, sleep therapy, and weight programs Thermography Experimental or investigational Services CT scans, MRIs, PET scans, bone scans, nuclear medicine, and any other types of diagnostic imaging or radiology other than X-rays covered under the Covered Services section of your Combined Chiropractic and Acupuncture Services Amendment Ambulance and other transportation Education programs, nonmedical self-care or self-help, any self-help physical exercise training, and any related diagnostic testing Services for pre-employment physicals or vocational rehabilitation Acupuncture performed with reusable needles Air conditioners, air purifiers, therapeutic mattresses, chiropractic appliances, durable medical equipment, supplies, or similar devices or appliances Drugs and medicines, including non-legend or proprietary drugs and medicines Services you receive outside the state of California, except for Emergency Chiropractic Services, Emergency Acupuncture Services, Urgent Chiropractic Services, or Urgent Acupuncture Services Hospital services, anesthesia, manipulation under anesthesia, and related services For Chiropractic Services, adjunctive therapy not associated with spinal, muscle, or joint manipulations For Acupuncture Services, adjunctive therapies unless provided during the same course of treatment and in conjunction with acupuncture Dietary and nutritional supplements, such as vitamins, minerals, herbs, herbal products, injectable supplements, and similar products Massage therapy Services provided by a chiropractor that are not within the scope of licensure for a chiropractor licensed in California Services provided by an acupuncturist that are not within the scope of licensure for an acupuncturist licensed in California Maintenance care (services provided to Members whose treatment records indicate that they have reached maximum therapeutic benefit) Definitions Acupuncture Services: The stimulation of certain points on or near the surface of the body by the insertion of needles to prevent or modify the perception of pain or to normalize physiological functions (including adjunctive therapies, such as acupressure, cupping, moxibustion, or breathing techniques, when provided during the same course of treatment and in conjunction with acupuncture) when provided by an acupuncturist for the treatment of your Neuromusculoskeletal Disorder, nausea (such as nausea related to chemotherapy, postsurgical pain, or pregnancy), or pain (such as lower back pain, shoulder pain, joint pain, or headaches). ASH Plans: American Specialty Health Plans of California, Inc., a California corporation. Chiropractic Services: Services provided or prescribed by a chiropractor (including laboratory tests, X-rays, and chiropractic appliances) for the treatment of your Neuromusculoskeletal Disorder. Neuromusculoskeletal Disorders: Conditions with associated signs and symptoms related to the nervous, muscular, or skeletal systems. Neuromusculoskeletal Disorders are conditions typically categorized as structural, degenerative, or inflammatory disorders, or biomechanical dysfunction of the joints of the body or related components of the motor unit (muscles, tendons, fascia, nerves, ligaments/capsules, discs, and synovial structures), and related neurological manifestations or conditions. Participating Acupuncturist: An acupuncturist who is licensed to provide Acupuncture Services in California and who has a contract with ASH Plans to provide Medically Necessary Acupuncture Services to you. A list of Participating Acupuncturists is available from the ASH Plans Member Services Department toll free at (TTY users call 711). The list of Participating Acupuncturists is subject to change at any time, without notice. If you have questions, please call the ASH Plans Member Services Department. Participating Chiropractor: A chiropractor who is licensed to provide Chiropractic Services in California and who has a contract with ASH Plans to provide Medically Necessary Chiropractic Services to you. A list of Participating Chiropractors is available from the ASH Plans Member Services Department at (TTY users call 711). The list of Participating Chiropractors is subject to change at any time, without notice. If you have questions, please call the ASH Plans Member Services Department. Participating Provider: A Participating Chiropractor, Participating Acupuncturist, or any licensed provider with which ASH Plans contracts to provide covered care, including laboratory tests or X-rays that are covered chiropractic care.

20 This is a summary and is intended to highlight only the most frequently asked questions about the chiropractic and acupuncture benefit, including cost shares. Please refer to the Combined Chiropractic and Acupuncture Services Amendment of the Kaiser Foundation Health Plan, Inc., Evidence of Coverage for a detailed description of the chiropractic and acupuncture benefits, including exclusions and limitations, Emergency Chiropractic Services, Emergency Acupuncture Services, Urgent Chiropractic Services, or Urgent Acupuncture Services. Kaiser Foundation Health Plan, Inc. (Health Plan) contracts with American Specialty Health Plans of California, Inc. (ASH Plans) to make the ASH Plans network of Participating Chiropractors and Participating Acupuncturists available to you. You can obtain covered Services from any Participating Chiropractor or Participating Acupuncturist without a referral from a Plan Physician. Your Cost Share is due when you receive covered Services. Please see the definitions section of your Combined Chiropractic and Acupuncture Services Amendment of the Kaiser Foundation Health Plan, Inc., Evidence of Coverage for terms you should know. CHIROACU 3057 NCAL_3058 SCAL (8-14) Please recycle.

21 Proposed Benefit Summary SISC-SELF INSURED SCHOOLS OF CALIFORNIA Principal Benefits for Kaiser Permanente HSA-Qualified Deductible HMO Plan (10/1/15 9/30/16) The Services described below are covered only if all of the following conditions are satisfied: The Services are Medically Necessary The Services are provided, prescribed, authorized, or directed by a Plan Physician and you receive the Services from Plan Providers inside our Southern California Region Service Area (your Home Region), except where specifically noted t o the contrary in the Evidence of Coverage (EOC) for authorized referrals, visiting Member care, hospice care, Emergency Services, Post- Stabilization Care, Out-of-Area Urgent Care, and emergency ambulance Services "Kaiser Permanente HSA-Qualified Deductible HMO Plan" is a health benefit plan that meets the requirements of Section 223(c)(2) of the Internal Revenue Code. This health benefit plan is a High Deductible Health Plan. The health care coverage described in t he EOC is designed to be compatible for use with a Health Savings Account (HSA) under federal tax law. Accumulation Period The Accumulation Period for this plan is 1/1/15 through 12/31/15 (calendar year). Out-of-Pocket Maximum You will not pay any more Cost Share during the calendar year if the Copayments and Coinsurance you pay, plus all your payments toward the Plan Deductible, add up to one of the following amounts: For self-only enrollment (a Family of one Member)... $3,000 per calendar year For an entire Family of two or more Members... $6,000 per calendar year Plan Deductible For Services subject to the Plan Deductible, you must pay Charges for Services you receive in the calendar year until you reach one of the following Plan Deductible amounts: For self-only enrollment (a Family of one Member)... $1,500 per calendar year For an entire Family of two or more Members... $3,000 per calendar year Note: The Plan Deductible amount is subject to increase if the U.S. Department of the Treasury changes the minimum deductible required in High Deductible Health Plans. Lifetime Maximum None Professional Services (Plan Provider office visits) Most Primary Care Visits for evaluations and treatment... 10% Coinsurance after Plan Deductible Most Specialty Care Visits for consultations, evaluations, and treatment... 10% Coinsurance after Plan Deductible Routine physical maintenance exams, including well-woman exams... No charge (Plan Deductible doesn't apply ) Well-child preventive exams (through age 23 months)... No charge (Plan Deductible doesn't apply ) Family planning counseling and consultations... No charge (Plan Deductible doesn't apply ) Scheduled prenatal care exams... No charge (Plan Deductible doesn't apply ) Routine eye exams with a Plan Optometrist for Members under age % Coinsurance after Plan Deductible Routine eye exams with a Plan Optometrist for Members age 19 and older... 10% Coinsurance after Plan Deductible Hearing exams... No charge (Plan Deductible doesn't apply ) Urgent care consultations, evaluations, and treatment... 10% Coinsurance after Plan Deductible Most physical, occupational, and speech therapy... 10% Coinsurance after Plan Deductible Outpatient Services Outpatient surgery and certain other outpatient procedures... 10% Coinsurance after Plan Deductible Allergy injections (including allergy serum)... 10% Coinsurance after Plan Deductible Most immunizations (including the vaccine)... No charge (Plan Deductible doesn't apply ) Most X-rays and laboratory tests... 10% Coinsurance after Plan Deductible Preventive X-rays, screenings, and laboratory tests as described in the EOC... No charge (Plan Deductible doesn't apply) Covered individual health education counseling... No charge (Plan Deductible doesn't apply ) Covered health education programs... No charge (Plan Deductible doesn't apply ) Hospitalization Services Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs... 10% Coinsurance after Plan Deductible Emergency Health Coverage Emergency Department visits... 10% Coinsurance after Plan Deductible Ambulance Services Ambulance Services... 10% Coinsurance after Plan Deductible S SISC-Self Insured Schools Of California (continues)

22 Proposed Benefit Summary (continued) Prescription Drug Coverage Covered outpatient items in accord with our drug formulary guidelines: Most generic items at a Plan Pharmacy... $10 for up to a 30-day supply after Plan Deductible Most generic refills through our mail-order service... $20 for up to a 100-day supply after Plan Deductible Most brand-name items at a Plan Pharmacy... $30 for up to a 30-day supply after Plan Deductible Most brand-name refills through our mail-order service... $60 for up to a 100-day supply after Plan Deductible Durable Medical Equipment (DME) DME items that are essential health benefits in accord with our DME formulary guidelines... 10% Coinsurance after Plan Deductible DME items that are not essential health benefits in accord with our DME formulary guidelines up to a $2,500 benefit limit per calendar year as described in the EOC... 10% Coinsurance after Plan Deductible Mental Health Services Inpatient psychiatric hospitalization... 10% Coinsurance after Plan Deductible Individual outpatient mental health evaluation and treatment... 10% Coinsurance after Plan Deductible Group outpatient mental health treatment... 10% Coinsurance after Plan Deductible Chemical Dependency Services Inpatient detoxification... 10% Coinsurance after Plan Deductible Individual outpatient chemical dependency evaluation and treatment... 10% Coinsurance after Plan Deductible Group outpatient chemical dependency treatment... 10% Coinsurance after Plan Deductible Home Health Services Home health care (up to 100 visits per calendar year)... No charge after Plan Deductible Other Skilled nursing facility care (up to 100 days per benefit period)... 10% Coinsurance after Plan Deductible Ostomy and urological supplies... No charge after Plan Deductible Prosthetic and orthotic devices that are essential health benefits... No charge after Plan Deductible Prosthetic and orthotic devices that are not essential health benefits... No charge after Plan Deductible Hospice care... No charge after Plan Deductible This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of-pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing suppli es) S SISC-Self Insured Schools Of California S

23 WELLS FARGO HEALTH SAVINGS ACCOUNT (HSA) FREQUENTLY ASKED QUESTIONS ADDITIONAL HEALTH SAVINGS ACCOUNT INFORMATION

24 Health Savings Account (HSA) - Important Information If you are considering enrolling in an account based health plan (ABHP) with a health savings account (HSA), please review this section carefully! 2016 annual limit for contribution $3,350 single/$6,750 double and family. This includes both the employee and employer contributions. HSA contributions are considered exempt for Federal Tax purposes. Employees may want to adjust State withholdings accordingly if participating in an ABHP plan. Employees cannot claim expenses for dependent on ABHP that is NOT a tax dependent. Employees cannot have an ABHP if covered on any other non-abhp plans through spouse, partner, etc. Employees cannot have a Flexible Spending Account (FSA) for medical expenses but can have one for dependent care. If you have an FSA, please spend all funds prior to December 31, You may not utilize the grace period if you enroll in an HSA. Employee & Employer Contributions will be reported in Box 12 of W-2 with Code W. IRS form 8889 will need to be completed for HSA. Wells Fargo will mail your their tax documents 1099-SA and 5498-SA each tax year which will provide the total contributions to and withdrawals from your account. Employees will need to inform their tax preparer, or if using a tax software, complete the questions pertaining to HSA accounts

25 Health Savings Account (HSA) Helping you get more for every healthcare dollar What is an HSA? A Wells Fargo HSA is like an IRA for your healthcare that empowers you to prepare for and manage healthcare costs. HSAs offer triple tax benefits, including tax-free 1 saving, growth, and spending on qualified medical expenses anytime, from today throughout your retirement something you can t get from other retirement accounts. HSAs complement your retirement plan, helping you prepare for the $250,000 2 or more that you will need for retirement medical expenses. HSAs can also be used to save and pay tax-free today for your healthcare expenses from doctor s visits to prescriptions, as well as dental and vision expenses. More than 15,000,000 people 3 have enrolled in an HSA. Here s why: HSAs can put extra money in your pocket HSA-qualified health insurance premiums are typically lower than other health insurance plans. If your premiums are lower, you can contribute the savings to your HSA it s like earning extra income, and it s saved in an account that is yours to keep. HSAs typically offer more benefits than FSAs Each offers tax-free contributions and spending on qualified medical expenses. Higher annual limits for contributions 4 mean more family tax savings potential with HSAs. HSA funds are yours to keep even if you don t use them, and carry forward year after year. HSAs are like IRAs for your healthcare You can use your HSA to save for healthcare expenses in retirement. You won t be taxed, even after you retire, as long as you use the money in your HSA for qualified medical expenses. Any investment gains you make are tax-free. Wells Fargo offers tools to help you research, manage, and optimize your investment opportunities. Benefit from tax savings The money you contribute to your HSA is tax-free 1 and can be used to pay for qualified medical expenses for you, your spouse, and your tax dependents. These tax savings can allow you to save up to $25 or more for every $100 contributed to your HSA. 6 Income tax savings Without an HSA With an HSA Income $1,000 $1,000 HSA contribution $0 $1,000 25% federal 6 income tax Money to spend on qualified medical expenses -$250 $0 $750 $1,000 HSAs offer the potential for investment growth You can invest in a broad range of HSA Mutual Funds. 5

26 view transaction history, order debit cards for your spouse and dependents, activate your investment account, and choose to receive online statements HSA contribution limits The maximum amount the IRS allows you to contribute to your HSA in 2015 is $3,350 for individual coverage and $6,650 for family coverage. 7 Plus, if you are aged 55 or older, you can contribute an additional catch-up contribution of $1,000. Check with your employer to see if you can contribute to your HSA with before-tax payroll deductions. Or, you can make contributions to your HSA up to the annual IRS contribution limits on an after-tax basis and deduct them from your return. Convenient payment options With a swipe of your Wells Fargo Visa HSA debit card, you can pay for prescriptions, doctor s visits, dental expenses, hearing aids, eyeglasses, and more. Each time you use your HSA debit card, expenses are automatically deducted from your HSA. You can also make withdrawals from your HSA by visiting any Wells Fargo store or Wells Fargo ATM. Easy account management tools Access your HSA online through Wells Fargo Online Banking by going to wellsfargo.com. Click on your HSA balance to access the Health Account Manager SM portal to HSAs offer the potential for investment growth The average couple retiring today may need up to $250,000 for medical expenses in retirement. 2 Wells Fargo is here to help you understand and prepare for those expenses. Once you reach a minimum balance in your FDIC-insured deposit account, you have the option to invest in a diverse range of HSA Mutual Funds. It s easy to find funds that meet a variety of long-term investment strategies. Tools are available to help you research, manage, and optimize your investment opportunities at our HSA Investment Center. And, through our relationship with Wells Fargo Advantage Funds, 8 investment professionals are available to assist you. 9 Getting started is easy Once you ve enrolled in an HSA-qualified health plan, it s easy to set up your Wells Fargo HSA. Simply follow the instructions specific to your employer s benefits enrollment process. Shortly after opening your account, you ll receive a welcome package in the mail. This packet includes all the information you need to start managing your HSA. Within a few days of receiving the welcome package, you ll receive your HSA debit card in a separate mailing, with instructions for using the card. How can we help? To learn more about maximizing the value of your HSA, or if you have questions about your HSA, call the HSA Customer Service team at , Monday through Friday, from 7:00 a.m. to 8:00 p.m. Central Time. 1 HSA contributions up to annual contribution limits are not subject to federal income tax. State taxes vary. Please consult a tax advisor for more information. 2 Individual situations may vary and not all costs may qualify for reimbursement from an HSA. Source: Anthony Webb and Natalia Zhivan, How Much is Enough? The Distribution of Lifetime Health Care Costs, Center for Retirement Research at Boston College (February 2010). 3 America s Health Insurance Plans, Center for Policy and Research (May 2012). 4 This is generally true if an individual is HSA-eligible for the full tax year. FSA salary reduction contributions are limited to $2,500 per employee in INVESTMENT PRODUCTS: NOT FDIC-INSURED NO BANK GUARANTEE MAY LOSE VALUE 6 This example is for illustrative purposes only. Savings may vary based on the tax bracket. HSA contributions up to annual contribution limits are not subject to federal income tax. State taxes vary, and some states do not recognize HSAs. Please consult a tax advisor for more information. 7 Personal limits may be lower than IRS maximums. Consult your tax advisor with questions. 8 Mutual fund investing involves risks, including the possible loss of principal. Consult a fund s prospectus for additional information on risks. Carefully consider a fund s investment objectives, risks, charges, and expenses before investing. For a current prospectus and, if available, a summary prospectus, containing this and other information, visit wellsfargoadvantagefunds.com. Read it carefully before investing. 9 The funds are distributed by Wells Fargo Funds Distributor, LLC, member FINRA/SIPC, an affiliate of Wells Fargo & Company (August 2012). wellsfargo.com/hsa Deposit products offered by Wells Fargo Bank, N.A. Member FDIC Wells Fargo Health Benefit Services, a division of Wells Fargo Bank, N.A. All rights reserved. WCS MC-2755 (6/14)

27 Health Savings Accounts (HSA) About HSAs Frequently asked questions (FAQs) for those considering a Wells Fargo HSA Are you considering enrolling in an HSA and want to know more about the benefits of an HSA and how it works? Review these helpful FAQs for more information. You can also call Wells Fargo HSA Customer Service at , or visit wellsfargo.com/hsa. About HSAs What is an HSA? An HSA is a tax-favored account that allows the accountholder to save and pay for qualified medical expenses tax-free. 1 To open an HSA, you must be in an HSA-qualified health plan. You can use funds in your HSA to pay for out-of-pocket expenses not covered by your health plan, as well as other qualified medical expenses. You own your HSA the account and funds in it stay with you year after year, even if you change employers or health plans. Who is eligible to open an HSA? To open an HSA, you must be enrolled in an HSA-qualified health plan and cannot be covered by a non-hsa-qualified health plan. You also cannot be enrolled in Medicare, be a dependent on another person s tax return, or have received VA medical benefits at any time over the past three months. If you have specific questions about your eligibility for an HSA, ask your benefits administrator or call Wells Fargo HSA Customer Service. What are the tax benefits associated with an HSA? HSAs enjoy triple tax benefits. The money you contribute to your HSA is tax-deductible and can be used to pay for qualified medical expenses for not only yourself, but also for your spouse and tax dependents tax-free. Interest earnings on your Federal Deposit Insurance Corporation (FDIC)-insured cash balance, plus investment 2 earnings if you choose to invest in your HSA, are also tax-free. How much can I contribute to an HSA? The maximum you can contribute annually to an HSA in 2015 is $3,350 for individual coverage and $6,650 for family coverage. If you are aged 55 or older, you can make an additional catch-up contribution. The maximum annual catch-up contribution is $1, Benefits of a Wells Fargo HSA Why should I choose the Wells Fargo HSA? A Wells Fargo HSA is like an IRA for your healthcare that empowers you to prepare for and manage healthcare costs. HSAs offer triple tax benefits, including tax-free saving, growth, and spending on qualified medical expenses anytime, from today throughout your retirement something you can t get from other retirement accounts. HSAs complement your retirement plan, helping you prepare for the $250,000 4 or more that you will need for retirement medical expenses. HSAs can also be used to save and pay tax-free today for your healthcare expenses from doctor s visits to prescriptions, as well as dental and vision expenses. What are the advantages of the Wells Fargo Visa HSA debit card? With a swipe of your HSA debit card, you can pay for prescriptions, doctor s visits, dental expenses, and more. You can use the HSA debit card anywhere Visa debit cards are accepted. You can also use it to make withdrawals at Wells Fargo ATMs. Can I access my HSA online and manage my account? Wells Fargo Online makes it fast and easy for you to manage your Wells Fargo HSA anytime, online. It provides all the tools you need to: View detailed account activity, including your HSA debit card transactions Maintain your account profile Make a one-time or recurring contribution to your HSA (current or prior year) Set up investment elections and automatic transfers to investments View online tax documents and monthly statements for up to seven years of statements Use online distributions to make one-time transfers into your Wells Fargo bank account a great way to reimburse yourself for out-of-pocket expenses Order debit cards for your dependents

28 What investment options are available in a Wells Fargo HSA? Wells Fargo offers a diverse array of HSA mutual fund options 2 to accommodate a range of investment objectives. Visit wellsfargo.com/hsainvesting to learn more about investing the funds in your HSA and the mutual fund choices available to you. HSA eligibility What is an HSA-qualified health plan? An HSA-qualified health plan is a health insurance plan with a minimum deductible of $1,300 for individual coverage or $2,600 for family coverage. The annual out-of-pocket expenses, which include deductibles and copays, cannot exceed $6,450 for individual coverage or $12,900 for family coverage. 5 How do I know if my health plan is HSA-qualified? Check with your employer or health insurance company to verify if your plan qualifies. What happens if I change jobs or health plans? HSAs are owned by the individual, so if you change jobs or health plans, you may keep your HSA at Wells Fargo and continue to spend HSA funds on qualified medical expenses. You may contribute to your HSA as long as you remain HSAeligible (for example, enrolled in an HSA-qualified health plan with no disqualifying coverage). How does FSA/HRA participation affect HSA eligibility? Participation in general Flexible Spending Accounts (FSAs) and Health Reimbursement Accounts (HRAs) makes you ineligible for an HSA. If your spouse is enrolled in a general-purpose FSA or HRA through his or her employer and that account can be used to pay for your medical expenses, you become ineligible for an HSA. However, if your employer offers a limited purpose (limited to dental, vision, or preventive care) or post-deductible (pay for medical expenses after the plan deductible is met) FSA or HRA, you may still be eligible for an HSA. Enrolling in the Wells Fargo HSA How do I enroll in the Wells Fargo HSA? If your employer offers an HSA-qualified health plan, you will need to enroll in that health plan first. Then you can follow the instructions specific to your employer s benefits enrollment process to set up your Wells Fargo HSA. 6 If you are an individual who would like to enroll in the Wells Fargo HSA and are enrolled in an HSA-qualified health plan, 5 go to wellsfargo.com/hsa and click Open an HSA. There is no fee to enroll online. What fees apply to a Wells Fargo HSA? There is a monthly service fee, which may be paid on your behalf by your employer. If you leave your employer or your employer does not pay the fee, it will automatically be debited from your HSA each month. The monthly service fee will be waived if the combined deposit and investment account 2 balance in your HSA on the last day of the month is greater than or equal to $5,000. The monthly service fee may vary based on your employer or insurance carrier relationship. Other than your monthly service fee, most common HSA services do not have an additional fee. Your HSA includes unlimited debit card transactions, ATM withdrawals at Wells Fargo ATMs, and no loads or transaction fees for buying and selling HSA mutual funds. 2 Additional banking fees may apply if you choose to use optional banking services or choose other non-standard services. See the accountholder fee schedule for complete information on the fees. Using HSA funds What are qualified medical expenses? To help you determine whether an expense qualifies for taxfree reimbursement under your HSA, Internal Revenue Code Section 213(d) states that eligible expenses must be made for medical care. This is defined as the amount paid for the diagnosis, cure, mitigation, treatment or prevention of disease, or for the purpose of affecting any structure or function of the body. Visit wellsfargo.com/hsaqualifiedexpenses for a more detailed list and explanation of qualified medical expenses. Examples of common qualified medical expenses include: Acupuncture Dental treatment Doctor s fees Hospital services Laboratory fees Prescription medicines or drugs Vision services X-rays Can I use funds from an HSA for non-qualified medical expenses? Yes, but you ll be required to pay income tax and a tax penalty of 20% on the amount you use for non-qualified medical expenses. (The 20% penalty doesn t apply to distributions made after your death or disability, or after you ve reached age 65.) Wells Fargo does not monitor whether you use your account for qualified medical expenses. 1 All tax references are at the federal level. State taxes vary. Please consult a tax advisor. 2 INVESTMENT PRODUCTS: NOT FDIC-INSURED NO BANK GUARANTEE MAY LOSE VALUE 3 These are the IRS contribution limits for Individual contribution limits may be lower than IRS maximums. Individuals are responsible for monitoring their contribution limits. Consult your tax advisor with questions about how limits apply to your situation. 4 Individual situations may vary and not all costs may qualify for reimbursement from an HSA. Source: Anthony Webb and Natalia Zhivan, How Much is Enough? The Distribution of Lifetime Health Care Costs, Center for Retirement Research at Boston College (February 2010). 5 Limits shown are for Limits are indexed for inflation and may change annually. 6 Other eligibility criteria may apply. You do not need to be HSA-qualified if you are only making a rollover contribution from another HSA. Deposit products offered by Wells Fargo Bank, N.A. Member FDIC Wells Fargo Health Benefit Services, a division of Wells Fargo Bank, N.A. All rights reserved. MC-3076 (05/15) WCS

29 Health Savings Account (HSA) Top reasons to enroll in an HSA HSAs offer many compelling benefits. Here s what you should know. 1 HSAs put extra money in your pocket Tax savings allow you to save up to $25 or more for every $100 contributed to your account 1 Learn more by watching a video at wellsfargo.com/usingyourhsa 2 HSAs typically offer more benefits than FSAs Each offers tax-free 2 contributions and spending on qualified medical expenses Higher annual limits for contributions 3 mean more family tax-saving potential with HSAs HSA funds are yours to keep even if you don t use them Unused HSA funds carry forward year after year and can be saved for retirement 3 HSAs are like IRAs for your healthcare Tax-free 2 contributions Save for healthcare expenses in retirement Potential for tax-advantaged 4 withdrawals in retirement 4 You may be able to contribute to your HSA through your employer with little or no change to your take-home pay 5 HSA-qualified health plan premiums are typically lower than other health plans If your premiums are lower, contribute the savings to your HSA it s like earning extra income, and it s saved in an account that you own 5 HSAs offer the potential of investment 6 growth Invest in a broad range of HSA mutual funds 6 Wells Fargo offers tools to help you research, manage, and optimize your investment opportunities Learn more by visiting our HSA investment center at wellsfargo.com/hsainvesting For more information visit wellsfargo.com/hsa or call Wells Fargo HSA Customer Service at , Monday through Friday, from 7:00 a.m. to 8:00 p.m. Central Time. INVESTMENT PRODUCTS: NOT FDIC INSURED NO BANK GUARANTEE MAY LOSE VALUE 1 Example is for illustrative purposes. Savings may vary based on tax bracket. HSA contributions up to annual contribution limits are not subject to federal income tax. State taxes vary, and some states do not recognize HSAs. Please consult a tax advisor for more information. 2 HSA contributions up to annual contribution limits are not subject to federal income tax. State taxes vary. Please consult a tax advisor for more information. 3 This is generally true if an individual is HSA-eligible for the full tax year. FSA salary reduction contributions are limited to $2,500 per employee in Individual situations may vary. Please consult your tax advisor. 4 Consult a financial planner or tax advisor for more information. 5 Individual situations vary. Check with your employer for more details. Deposit products offered by Wells Fargo Bank, N.A. Member FDIC Wells Fargo Health Benefit Services, a division of Wells Fargo Bank, N.A. All rights reserved. WCS MC-4508 (09/14)