go with ^ Access+ HMO blueshieldca.com blueshieldca.com/sfhss For active employees, early retirees, and Medicare Coordinated retirees

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1 go with ^ Access+ HMO For active employees, early retirees, and Medicare Coordinated retirees blueshieldca.com/sfhss blueshieldca.com

2 Go with the plan that s right for you When you go with Blue Shield, you re off and running with reliable access to quality health coverage, large provider networks, and a wide range of proven programs and services that help you get the most value from your coverage. In this booklet, you ll find the information you need to choose the right health plan for you and your family, including: ii HMO plan benefits and features Pharmacy benefits How to find a doctor dditional programs and services A available to Blue Shield members Blue Shield of California

3 Blue Shield makes it easy to make the right choices for your healthcare coverage Blue Shield Access+ HMO plan (health maintenance organization) Choosing a Personal Physician is one of the keys to using an HMO plan. HMO members must access covered services through a network of physicians and facilities as directed by their Personal Physician. Exceptions include emergencies and urgent care received outside of a member s Personal Physician s service area. The Access+ HMO plan may be a good choice and a cost-efficient way to maintain your health if you and your family go to the doctor often. Choosing a Personal Physician: When you enroll in a Blue Shield Access+ HMO plan, you ll be assigned a primary care physician for you and your dependents. At Blue Shield, we call them Personal Physicians. If you are new to Blue Shield, we will automatically assign a Personal Physician to you and your eligible family members at the time of enrollment based on the address you provide on the HSS Open Enrollment application form. Once you receive your member ID card, you can change your or your eligible family member s Personal Physician anytime for any reason, by calling call Blue Shield Member Services at (800) It s easy to search for a Personal Physician, to find out if your current doctor is in our network, and to find out which hospitals and other care facilities are affiliated with your personal physician s medical group. Just follow the steps under Find a network provider on page 6. If you don t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team at (800) for personal assistance or to request a provider directory plan changes There are benefit changes for the July 1 December 31, 2012 plan year. Additional benefit changes are indicated in blue bold in the Access+ HMO Benefits Summary on page 3. For complete details about this plan, refer to the 2012 Access+ HMO Evidence of Coverage and Disclosure (EOC&D) booklet or visit blueshieldca.com/sfhss. $25 copay for physician and specialist office visits $100/outpatient surgery either in a hospital or ambulatory surgical center $200 per admission for inpatient hospitalization $10 formulary generic, $25 formulary brand, and $50 non-formulary brand copays for retail prescriptions $20 formulary generic, $50 formulary brand, and $100 non-formulary brand copays for mail-service prescriptions Healthy Lifestyle Rewards Earn up to $175 in cash rewards when you participate and adopt healthy lifestyle habits. Receive $75 when you take a Wellness Assessment and $50 when you enroll in the Quit For Life tobacco cessation program. Earn another $50 for completing an online Health Program. In lieu of enrolling in the Quit For Life program, you can opt to complete an additional online Health Program for $50. Learn more about Blue Shield online Learn what Blue Shield members are saying about their health plan visit blueshieldca.com/bsc/reviews. Read inspiring Member Stories shared by Blue Shield members visit blueshieldca.com/memberstories. blueshieldca.com 1

4 Plan features HMO plan Out-of-pocket costs Pay a copayment for covered services. Choosing a doctor Select a Personal Physician to coordinate all your medical care. You cannot go outside the Blue Shield network except in emergencies. Access to specialists Get a referral from your Personal Physician or self-refer to specialists within your Personal Physician s medical group or IPA for a higher copayment. * Programs & Services NurseHelp 24/7 SM LifeReferrals 24/7 SM Healthy Lifestyle Rewards Prenatal Program Health Management Programs * 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 SM visits for mental health services must be provided by an MHSA network participating provider. 2 Blue Shield of California

5 Plan benefits To learn more about the Access+ HMO plan, please see the Benefits Summaries on page 9. HMO plan Annual deductible None Annual out-of-pocket maximum or copayment maximum $2,000 per individual/$4,000 per family Preventive care No charge Office visit $25/visit Diagnostics (such as lab work) No charge Maternity coverage* No charge Chiropractic services $15/visit Rehabilitation (physical and occupational therapy) $25/visit Emergency room visits Hospital care $100/visit $200 per admission inpatient $100 per surgery outpatient * Prenatal and postnatal physician office visits. For inpatient hospital services, see Hospitalization Services in the benefit summary in the back of this booklet. Member confidentiality Blue Shield protects the confidentiality and privacy of your personal and health information, including medical information and individually identifiable information such as your name, address, telephone number, and Social Security number. To ensure this, Blue Shield requires a signed authorization form for you to access health information for your spouse or dependents over the age of 18. To request an authorization form, log in to blueshieldca.com and select My Health Plan. Click on Download Forms under Shortcuts on the right side. Scroll down to Release of information and click on Personal and Health Information Release. If you don t have access to the Internet, or have questions about how Blue Shield protects your privacy and confidentiality, please call our Privacy Office directly at (888) blueshieldca.com 3

6 Pharmacy benefits Check our formulary It s easy to access the Blue Shield Drug Formulary to see if your medication is in our list of preferred prescription drugs. Go to blueshieldca.com and click on Pharmacy for our drug database and formulary selection. If you don t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team at (800) for personal assistance or to request a copy of our formulary. Prescriptions by mail Members who take stabilized doses of covered long-term maintenance medications for conditions such as diabetes can order a mail-service refill of up to a 90-day supply. You may save money on your copayment and there is no charge for shipping. It s easy to get started. All you will need is a prescription from your doctor and a completed Prim New Order form. You can download the Prim New Order form by going to blueshieldca.com, clicking on Pharmacy, and then Mail-Service Pharmacy. Or, you can call Prim at (866) to request a form. After you send your order form and prescription to Prim , you can order refills online by going to We re here to help. If you have any questions, simply contact your Blue Shield Member Services team at (800) for personal assistance, from 7 a.m. to 7 p.m., Monday through Friday. 4 Blue Shield of California

7 HMO plan Member copayment Participating pharmacy Non-participating pharmacy Annual deductible * None Retail prescriptions (for up to a 30-day supply) Formulary generic drugs $10 per prescription Not covered Formulary brand-name drugs $25 per prescription Not covered Non-formulary brand-name drugs $50 per prescription Not covered Mail-service prescriptions (for up to a 90-day supply) Formulary generic drugs $20 per prescription Not covered Formulary brand-name drugs $50 per prescription Not covered Non-formulary brand-name drugs $100 per prescription Not covered * Prescription drug coverage benefits are not subject to the medical plan deductible. blueshieldca.com 5

8 Find a network provider Blue Shield s Access+ HMO network is one of the largest in California with more than 34,000 physicians and 297 hospitals Brown & Toland Medical Group, Chinese Community Health Care Association, Palo Alto Medical Foundation, and Hill Physicians Medical Group, in addition to California Pacific Medical Center, UCSF Medical Center, John Muir Health, and more. You do not need to log in to find a provider on blueshieldca.com; simply follow the instructions below. If you are an existing member and have registered on the site, log in and you ll automatically be directed to your plan network. Search for an HMO network provider online Go to blueshieldca.com/findaprovider. Next to Select a plan, click on the Select button. Changing your doctor after open enrollment If you would like to change your Personal Physician, simply log in to blueshieldca.com, select My Health Plan, and click on Change Personal Physician under Medical Plan Overview. Or, you can call Blue Shield Member Services at (800) to let them know your choice. In most cases, the change will be effective on the first day of the month following your request. Under Medical Plan, choose Access+ HMO, then Access+ HMO as the subplan, and click on Set plan. Find out your provider s quality of care rankings Select the type of provider that you are searching for. You can easily access quality scores, efficiency indicators, patient satisfaction scores, and cost information for many individual physicians, HMO medical groups, and hospitals. To see a provider s performance profile, simply click on the name of the doctor, HMO medical group, or hospital from your search results. Click on Advanced Search to further filter your search, such as by name, specialty, facility type, and more. Enter your city and state or ZIP code, then click on Find now. The default distance/radius search is 15 miles. To expand or narrow the search radius, click on zoom (+ or -) in the map on the provider search results page. 6 How to find a Personal Physician: Select HMO Personal Physicians under Filter results by on the left. Click on the physician s name to find the provider number, medical group/ipa number (needed when you enroll in the Access+ HMO for the first time), and to find out which hospitals and other care facilities are affiliated with your personal physician s medical group. Before you choose a Personal Physician, make sure the one you choose is accepting new patients by calling the physician s office. If you don t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team at (800) for personal assistance or to request a provider directory. Blue Shield of California

9 Discover more Additional Benefits Behavioral health benefits Your behavioral health benefits include inpatient and outpatient mental health and substance abuse care for issues such as: Depression Alcohol/drug abuse Mental illness Marriage and family counseling The services are provided by Blue Shield s mental health service administrator (MHSA) network. HMO members only have access to MHSA network providers. Care away from home Through the BlueCard Program, Access+ HMO members can access emergency and urgent care services across the country and around the world. You can receive urgent care services from any provider; however, using the BlueCard Program can be more cost-effective and eliminate the need for you to pay for the services when they are rendered and submit a claim for reimbursement. You can locate a BlueCard provider at any time by calling (800) 810-BLUE or by going to the Find a Provider section of blueshieldca.com. The Away From Home Care program gives students, long-term travelers, workers on extended out-of-state assignments, and families living apart the convenience and flexibility of coverage for extended periods across the country. To learn more about Away From Home Care and whether your family is eligible, call your Blue Shield Member Services team at (800) Please note that Away From Home Care is not available in all areas and states, and benefits from the host plan may differ from the Access+ HMO plan. Programs and services As a member, you can register at blueshieldca.com and find more information about these programs. Healthy Lifestyle Rewards Earn up to $175 in cash rewards when you participate and adopt healthy lifestyle habits. Receive $75 when you take a Wellness Assessment and $50 when you enroll in the Quit For Life tobacco cessation program. Earn another $50 for completing an online Health Program. In lieu of enrolling in the Quit For Life program, you can opt to complete an additional online Health Program for $50. Quit For Life (tobacco cessation) When you are ready to quit tobacco, you don t have to face the challenge by yourself. The Quit For Life tobacco cessation program provides a specialized, highly trained coach to help you implement the strategies necessary to successfully quit tobacco for life. Participants in the program receive up to five outbound coaching calls and unlimited toll-free access to a Quit Coach for the duration of the program, as well as nicotine-replacement therapy, a printed workbook, and access to an online community comprising e-learning tools, social support, and information about quitting. For more information on how to enroll in the program, please visit quitnow.net/blueshieldca. NurseHelp 24/7 To talk with registered nurses any time, day or night, and get answers to your health-related questions, or go online to have a one-on-one personal chat with a registered nurse anytime. The NurseHelp 24/7 SM phone number is conveniently located on the back of your member ID card. LifeReferrals 24/7 Call anytime to talk with a team of experienced professionals ready to assist you with personal, family, and work issues. Get referrals for three face-to-face visits (in a six-month period) with a licensed therapist at no cost to you (available only in California). The LifeReferrals 24/7 SM phone number is conveniently located on the back of your member ID card. Prenatal Program This program gives you 24/7 access to experienced maternity nurses as well as prenatal information, including a popular pregnancy or parenting book, at no additional cost. Some materials available in Spanish. Call (888) to enroll. Health management programs Your Blue Shield health plan is complemented by a wide range of helpful programs that offer support for members with asthma, diabetes, coronary artery disease, heart failure, and chronic obstructive pulmonary disease. blueshieldca.com 7

10 Discover more (continued) Wellness discount programs We offer a variety of member discounts on popular programs 1 that can help you save money and get healthier. Weight Watchers Get discounts on three- and 12-month subscriptions, monthly passes, and at-home kits (does not include Weight Watchers at Work). 24 Hour Fitness Enjoy waived enrollment fees and discounts on monthly membership dues. ClubSport and Renaissance ClubSport 2 Get a 60% discount on enrollments when joining with a month-tomonth agreement. Enrollment fees are waived when joining with a 12-month agreement. (There is a one-time $25 processing fee when you enroll.) drugstore.com Save on health and wellness products. Alternative Care Discount Program 2 Save at least 25% on acupuncture, massage therapy, and chiropractic services, plus get discounts on health and wellness products. Vision services Get 20% off the published retail prices when you use a participating provider 3 in the Discount Vision Program network for exams, frames, lenses, and more. QualSight LASIK Members in California receive a 20% discount off providers usual and customary fees on traditional and custom LASIK surgery. TLCVision LASIK 4 Get 15% off providers usual and customary fees for LASIK and PRK correction surgery through a TLCVision or NVision network provider in California. Members who live outside California get a 10% discount off providers usual and customary fees from TLCVision providers. Your VIP pass is at blueshieldca.com As a Blue Shield member, you can register at blueshieldca.com for an all-access pass to convenient features all in one secure place and customized just for your health plan. You can get benefit details for covered services, find network doctors and facilities, print temporary ID cards, and more! The network of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy. Nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products. Some services offered through the discount program may already be included as part of the Blue Shield plan covered benefits. Members should access those covered services prior to using the discount program. Members who are not satisfied with products or services received from the discount program may use Blue Shield s grievance process described in the Grievance Process section of the Evidence of Coverage. Blue Shield reserves the right to terminate this program at any time without notice. Discount programs administered by or arranged through the following independent companies: Alternative Care Discount Program American Specialty Health Networks, Inc. (ASH Networks) Discount Vision Program MESVision Weight control Weight Watchers North America Fitness facilities 24 Hour Fitness, ClubSport, and Renaissance ClubSport Health products (excluding prescription drugs) drugstore.com inc. LASIK Laser Eye Care of California, LLC, QualSight Inc., and TLCVision Corporation Note: No genetic information, including family medical history, is gathered, shared, or used from these programs. 1 These discount program services are not a covered benefit of Blue Shield health plans, and none of the terms or conditions of Blue Shield health plans apply. Discount program services are available to all members with a Blue Shield medical, dental, vision, or life* insurance plan Hour Fitness, ClubSport/Renaissance ClubSport, and Alternative Care Discount Program are not available in all states. Members should contact their local 24 Hour Fitness or ClubSport gym, or American Specialty Health Network (ASH) provider to determine whether a Blue Shield of California discount applies. To find an ASH provider, call (877) or go to blueshieldca.com/findaprovider. 3 For Discount Vision Program providers in California, go to blueshieldca.com and search for Routine Care Discount Vision Program. For providers outside California, go to ecndiscount.com. 4 TLC Centers are not available in all states. To find a TLC Center near you, call (877) TLC * Life Insurance plans are underwritten by Blue Shield of California Life & Health Insurance Company. 8 Blue Shield of California

11 Review benefit summaries City and County of San Francisco Custom HMO Inpatient Group # s H11054 & H12054 Benefit Summary (For groups of 300 and above) (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 July 1, 2012 Plan year medical deductible None Plan year copayment maximum 1 (For many covered services) $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 Injectable medications (other than injectables for allergy) 10 No Charge Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $25 per visit Access+ Specialist SM Benefits (Self-referred office visits and consultations only) 1, 2 Office visit, Examination or Other Consultation $30 per visit Preventive Health Benefits Preventive Health Services (see the description of Preventive Health Services in the definitions No Charge section of the Evidence of Coverage for more information) OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery Center 3 $100 per surgery Outpatient surgery in a hospital $100 per surgery Outpatient Services for treatment of illness or injury and necessary supplies (Except No Charge as described under "Rehabilitation benefits" and "Speech therapy benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient Physician Services No Charge Inpatient Non-emergency Facility Services (semi-private room and board, medically $200 per admission necessary services and supplies) Inpatient Medically Necessary skilled nursing Services including Subacute Care 4 No Charge EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission (Copayment does not apply if the $100 per visit member is directly admitted to the hospital for inpatient services). Emergency room Physician Services No Charge AMBULANCE SERVICES Emergency or authorized transport $50 An Independent Member of the Blue Shield Association blueshieldca.com 9

12 PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits 1 A description of your outpatient prescription drug coverage is provided separately. If you do not have the separate drug summary that goes with this benefit summary, please contact your benefits administrator or call Member Services at (800) 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 Durable Medical Equipment (member share is based upon allowed charges) 1 No Charge MENTAL HEALTH SERVICES (PSYCHIATRIC) 5 Inpatient Hospital Services $200 per admission Outpatient Mental Health Services $25 per visit CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 6 Please see footnote 7 Chemical dependency and substance abuse services Not Covered HOME HEALTH SERVICES Home health care agency Services (up to 100 visits per Plan Year) $25 per visit Physician s home visits $25 per visit Medical supplies and laboratory Services (See "Prescription Drug Coverage" for specialty No Charge drugs) HEARING AID SERVICES Audiological examination No Charge Hearing Aid (up to a maximum of $2,500 per member every 36 months for the hearing aid equipment No Charge and ancillary equipment) OTHER Hospice Program Benefits Routine home care No Charge Inpatient Respite Care No Charge 24-hour Continuous Home Care No Charge General Inpatient care No Charge Pregnancy and Maternity Care Benefits Prenatal and Postnatal Physician Office Visits No Charge (For inpatient hospital services, see "Hospitalization Services.") Family Planning and Infertility Benefits Counseling and consulting $25 per visit Infertility Services (member share is based upon allowed charges) (Diagnosis and treatment of cause 50% of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation 8, 9 $100 per surgery Elective abortion 8 $100 per surgery 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 location (Copayment applies to all places of service including professional and facility settings) $25 per visit Diabetes Care Benefits Devices, equipment, and non-testing supplies (member share is based upon allowed charges) No Charge (For testing supplies, see "Outpatient Prescription Drug Coverage Summary.") Diabetes self-management training $25 per visit Urgent Care Benefits (BlueCard Program) Urgent Services outside your Personal Physician Service Area $50 per visit Optional Benefits 1 Optional dental, vision, infertility, substance abuse, chiropractic or chiropractic and acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. 10 Blue Shield of California

13 1 Copayments marked with a (1) do not accrue to plan-year copayment maximum. Copayments and charges for services not accruing to the member's plan-year copayment maximum continue to be the member's responsibility after the plan-year copayment maximum is reached. Please refer to the Evidence of Coverage, and the plan contract for exact terms and conditions of coverage. 2 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. 3 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits. 4 Skilled nursing services are limited to 100 preauthorized days during a plan 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 services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage or plan contract. 6 Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield HMO providers. 7 Optional substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as "Additional Substance Abuse Treatment Benefits." 8 Physician services copayment in the office or outpatient hospital facility only. If procedure is performed in a hospital facility setting, additional hospital services copayment may apply. 9 Copayment does not apply when procedure is performed in conjunction with delivery or abdominal surgery. 10 Serum administered during the office visit is included. For serum purchased separately from the office, the member is responsible for 50% of the allowed charges. Plan designs may be modified to ensure compliance with state and federal requirements. Plan designs may be modified to ensure compliance with state and federal requirements. A16205 (1/12) AA blueshieldca.com 11

14 City and County of San Francisco Group # s H11054 & H12054 Custom Access+ HMO Plan Outpatient Prescription Drug Coverage (For groups of 300 and above) THIS DRUG SUMMARY IS INTENDED TO BE USED WITH THE ACCESS+ HMO OR ADDED ADVANTAGE POS PLANS UNIFORM HEALTH PLAN BENEFITS AND COVERAGE MATRIX. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Blue Shield of California Highlight: 3-Tier/Incentive Formulary $0 Plan Year Brand-Name Drug Deductible $10 Formulary Generic/$25 Formulary Brand Name/$50 Non-Formulary Brand Name Drug - Retail Pharmacy $20 Formulary Generic/$50 Formulary Brand Name/$100 Non-Formulary Brand-Name Drug - Mail Service Covered Services DEDUCTIBLES (Prescription drug coverage benefits are not subject to the medical plan deductible.) Plan-year brand-name drug deductible Member Copayment None PRESCRIPTION DRUG COVERAGE 1 (Includes oral contraceptives, diaphragms, and covered diabetic drugs and testing supplies) Participating Pharmacy Non-Participating Pharmacy Retail prescriptions (For up to a 30-day supply) Formulary generic drugs $10 per prescription Not Covered Formulary brand name drugs 2, 3 $25 per prescription Not Covered Non-formulary brand name drugs 2 $50 per prescription Not Covered Mail service prescriptions (For up to a 90-day supply) Formulary generic drugs $20 per prescription Not Covered Formulary brand name drugs 2, 3 $50 per prescription Not Covered Non-formulary brand name drugs 2 $100 per prescription Not Covered Specialty Pharmacies (For up to a 30-day supply) 4 Specialty drugs 5 20% (Up to $100 copayment maximum per prescription) Not Covered 1 Copayments and charges for these covered services are not included in the calculation of the member's medical Plan-year copayment maximum and continue to be the member's responsibility after the Plan-year copayment maximum is reached. Please refer to the Evidence of Coverage and Plan Contract for exact terms and conditions of coverage. Please note that if you switch from another plan, your prescription drug deductible credit from the previous plan during the Plan year, if applicable, will not carry forward to the new plan. 2 Selected formulary and non-formulary drugs require prior authorization for Medical Necessity, and when effective, lower cost alternatives are available. 3 If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the generic drug co-payment plus the difference in cost to Blue Shield between the brand-name drug and its generic drug equivalent. 4 Specialty Drugs are specific Drugs that usually require close monitoring and are used to treat complex or chronic conditions 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 selfadministered in the home by injection by the patient or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Infused or Intravenous (IV) medications are not included as Specialty Drugs. These 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. 5 Specialty-drugs are covered only when dispensed by select pharmacies in the Specialty Pharmacy Network unless Medically Necessary for a covered emergency. Note: This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. Important Prescription Drug Information An Independent Member of the Blue Shield Association 12 Blue Shield of California

15 You can find details about your drug coverage three ways: 1. Check your Evidence of Coverage. 2. Go to blueshieldca.com and log onto My Health Plan from the home page. 3. Call Member Services at the number listed on your Blue Shield member ID card. At Blue Shield of California, we're dedicated to providing you with valuable resources for managing your drug coverage. Go online to the Pharmacy section of blueshieldca.com and select the Drug Database and Formulary to access a variety of useful drug information that can affect your out-of-pocket expenses, such as: Look up non-formulary drugs with formulary or generic equivalents; Look up drugs that require step therapy or prior authorization; Find specifics about your prescription copayments; Find local network pharmacies to fill your prescriptions. TIPS! Using the convenient mail service pharmacy can save you time and money. If you take a consistent dose of a covered maintenance drug for a chronic condition, such as diabetes or high blood pressure, you can receive up to a 90-day supply through the mail service pharmacy with a reduced copayment. Call the mail service pharmacy at (866) Members using TTY equipment can call TTY/TDD Plan designs may be modified to ensure compliance with state and federal requirements. A16149-d (1/12) AA blueshieldca.com 13

16 City and County of San Francisco Substance Abuse Treatment Benefits Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix) For Access+ HMO Plans Group # s H11054 & H12054 How the Plan Works In addition to the benefits listed in the Benefit Summary, your health plan also covers inpatient hospital and professional (physician) services for substance abuse treatment and rehabilitation provided via hospitalization or partial hospitalization/day treatment. 1 All services must be medically necessary. Blue Shield of California has contracted with a Mental Health Service Administrator (MHSA), a licensed specialized health care service plan, to administer and deliver these services from MHSA participating providers. The MHSA is only the administrator for participating providers. Blue Shield of California does not provide benefits for services provided by non-participating providers. Coverage Details Residential care is not covered. Covered Services Member Copayment 2 MHSA Participating Provider Inpatient Hospitalization and residential treatment Inpatient Hospitalization Copay Applies Professional (Physician) Services - Inpatient and Outpatient Physician Visit Partial Hospitalization/Day Treatment 1. Except for emergencies, benefits are covered only when pre-authorized by the MHSA. 2. Please refer to the Medical Benefit Summary for applicable copayment responsibility. Physician Visit Copay Applies Ambulatory Surgery Copay Applies A17277 (01/12 AA This document is only a summary for informational purposes. It is not a contract. Please refer to the Plan Contract and Evidence of Coverage for the exact terms and conditions of coverage. 14 Blue Shield of California

17 Chiropractic and Acupuncture Benefits Additional coverage for City and County of San Francisco Group # s H11054 & H12054 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 Access+ HMO or Added Advantage 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 Plan-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 and laboratory tests (chiropractic only) Benefit Plan Design Plan-year Maximum 30 Visits Chiropractic 30 Visitis Acupuncture A17273 (01/12 AA Plan-year Deductible None Plan-year Chiropractic Appliances Benefit 1,2 $50 Covered Services Acupuncture Services Chiropractic Services Out-of-network Coverage Member Copayment $15 per visit $15 per visit None 1. Chiropractic appliances are covered up to a maximum of $50 in a Plan-year as authorized by ASH Plans. 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. blueshieldca.com 15

18 Additional Blue Shield Infertility Benefits City and County of San Francisco Group # s H11054 & H12054 How the Plan Works Your health plan includes infertility benefits in addition to those listed in the Benefit Summary (Uniform Benefits and Coverage Matrix 1 ). Coverage includes authorized professional, hospital, ambulatory surgery center, and ancillary services, as well as injectable drugs administered or prescribed to diagnose the cause, and treatment of infertility 2. Coverage Details The following procedures are limited, per plan-year as shown. Six (6) natural (without ovum/egg [oocyte or ovarian tissue] stimulation) artificial inseminations and; Three (3) stimulated (with ovum/egg [oocyte or ovarian tissue] stimulation) artificial inseminations and; The following procedures are limited, per lifetime as shown. One (1) gamete intrafallopian transfer (GIFT), in-vitro fertilization (IVF), or zygote intrafallopian transfer (ZIFT) Cryopreservation of sperm/ oocyte /embryos for a condition when retrieved from a covered Subscriber, spouse, or Domestic Partner. Benefits are limited to one retrieval and one year of storage per person per lifetime All benefits are subject to a copayment. Plan Options Access+ HMO Plans Plans Copayment 50% of the allowable amount 1. If you are an Access+ HMO member, services that diagnose and treat infertility are included in your basic plan benefits. 2. These services are covered only when authorized by Blue Shield, and provided by a Preferred Provider.. Procedures must be consistent with established medical practice in treatment of infertility and induced fertilization. A /12 AA This is only a summary for informational purposes. It is not a contract. Please refer to the plan contract and Evidence of Coverage for a detailed description of covered benefits and limitations. 16 Blue Shield of California

19 Notice on the availability of language assistance services to accompany vital documents issued in English

20 we re here to help If you have any questions, visit blueshieldca.com or call your dedicated Blue Shield Member Services team at (800) , from 7 a.m. to 7 p.m., Monday through Friday. Blue Shield of California is an Independent Member of the Blue Shield Association A37282 CCSF (3/12)