Find the plan that s right for you

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1 Take a glance at what our plans have to offer Plans at a glance for s and families Effective January 1, 2014 Find the plan that s right for you Our easy-to-understand plans offer comprehensive benefits to make it simple to find a plan that fits you and your family s needs. All of our plans offer the essential health benefits required by the Affordable Care Act (ACA), including preventive care services without a copayment, brand-name and generic prescription drug coverage, hospitalization benefits, pediatric dental and vision coverage, and more! Your broker can assist you in applying for a Blue Shield plan through Blue Shield or through Covered California ( California s health insurance marketplace. You may be eligible for federal premium assistance to help pay your monthly premiums for any Blue Shield plan (except the Get Covered plan) through Covered California. Contact your broker or Blue Shield to guide you through the qualification process. Ultimate plan (Platinum level): Basic plan (Bronze level): Blue Shield pays, on average, 90% of covered medical expenses Blue Shield pays, on average, 60% of covered medical expenses Our Ultimate plan offers you the lowest out-of-pocket costs for medical services. There are no deductibles, so we start paying for covered benefits right from the start. By paying a higher monthly premium, you ll pay less for medical services such as doctor visits, prescription drugs, and hospitalization. With low monthly rates in exchange for a higher deductible and more out-of-pocket costs when accessing services, the Basic plan is a good choice if you want to know you ve got the coverage you need when you need it most. Most services are subject to the medical deductible, but you ll still receive important benefits like preventive care and three doctor visits for a fixed copayment before meeting the deductible. Preferred plan (Gold level): Blue Shield pays, on average, 80% of covered medical expenses Basic for HSA plan (Bronze level): Our Preferred plan offers exceptio nal coverage with manageable out-of-pocket costs, so it s easier to predict additional expenses. There are no deductibles, so we start paying for covered benefits immediately, including popular benefits such as doctor visits, prescription drugs, and urgent care. Blue Shield pays, on average, 60% of covered medical expenses Enhanced plans (Silver level): Blue Shield pays, on average, 70% of covered medical expenses Our Enhanced plan offers you affordable, comprehensive coverage without surprises. You ll receive benefits like doctor visits and generic drugs prior to meeting a moderate deductible. Other services, such as hospitalization, are covered after you meet the medical deductible. By paying a little more when you use services, you ll pay lower monthly rates. We also offer Enhanced cost-sharing reduction plans through Covered California for those who meet federal financial guidelines. These plans provide you with lower cost-sharing to reduce your out-of-pocket costs when accessing medical care. Contact your broker or Blue Shield to help you determine if you qualify for one of these plans.! i These plans are pending regulatory approval. Our Basic plan for health savings accounts is perfect for those who want low monthly rates and to better manage their healthcare spending through a health savings account (HSA). With this HSA-compatible,* high-deductible health plan, you can prepare for future medical costs by contributing pre-tax money to your own savings account for healthcare expenses. You ll even enjoy preventive care before meeting the deductible. Get Covered plan (Catastrophic): Blue Shield pays, on average, 60% of covered medical expenses Get Covered is designed specifically for people under age 30, or those age 30 and above who can provide a certification that they are without affordable coverage or are experiencing financial hardship, and need to purchase a low-cost plan option. The plan carries a high deductible. Most services are subject to the medical deductible, but you ll still receive important benefits like preventive care and three doctor visits for no additional cost before meeting the deductible. * Although most s who enroll in an HSA-compatible health plan are eligible to open an HSA, you should consult with a financial adviser to determine if an HSA/HDHP is a good financial fit for you. Blue Shield does not offer tax advice for HSAs. HSAs are offered through financial institutions. For more information about HSAs, eligibility, and the law s current provisions, you should ask your financial or tax adviser.

2 Plan comparison chart Blue Shield offers a variety of comprehensive Preferred Provider Organization (PPO) or Exclusive Provider Organization (EPO) health plans for you to choose from. With our PPO and EPO plans, you can see any doctor or hospital in one of Blue Shield s Exclusive provider networks where you ll receive the most care for your dollar. Only PPO plans, however, also offer coverage for services received from providers outside of our networks. EPO plans only cover non-network provider services in emergency situations. Visit blueshieldca.com/findaplan to determine if PPO or EPO plans are available in your area. All plans also include physical therapy, ambulance, mental health, substance abuse, radiology, home health, skilled nursing benefits, and more. Our PPO plans offer coverage for non-participating providers as well. This is not a contract. All benefit descriptions are an overview of plan benefits. For a detailed description of plan benefits and exclusions, please request a copy of the Evidence of Coverage (EOC) or Policy by calling us at (888) We also have Summary of s and Coverage Forms that can help you make a decision by providing you with an easy-to-understand overview of what these plans cover. Visit blueshieldca.com/sbc or call (888) to obtain the forms. Compare our plans to find the level of coverage you re looking for. ULTIMATE PLAN (PLATINUM) PREFERRED PLAN (GOLD) PLAN (SILVER) With participating providers, members pay 1 : 150 SUBSIDY* PLAN (SILVER) 200 SUBSIDY* PLAN (SILVER) Office visit primary care doctor $20 $30 $45 $3 $15 Office visit specialist doctor $40 $50 $65 $5 $20 Urgent care visit $40 $60 $90 $6 $30 Preventive health benefits $0 $0 $0 $0 $0 Inpatient hospitalization 10% 20% 20% 10% 15% Outpatient surgery 10% 20% 20% 10% 15% Lab $20 $30 $45 $3 $15 X-ray $40 $50 $65 $5 $20 Emergency room services not resulting in admission $150 $250 $250 $25 $75 Maternity 10% 20% 20% 10% 15% Generic drugs $5 $19 $19 $3 $5 Preferred brand drugs $15 $50 $50 $5 $15 Non-preferred brand drugs $25 $70 $70 $10 $25 Chiropractic Not covered Not covered Not covered Not covered Not covered Acupuncture (from a licensed acupuncturist) $20 $30 $45 $3 $15 Pediatric eye exam $0 $0 $0 $0 $0 Pediatric eyeglasses $0 $0 $0 $0 $0 Calendar-year medical deductible 2 $0 $0 Calendar-year out-of-pocket maximum (includes deductible) $4,000 per / $8,000 per family $6,350 per / Calendar-year brand drug deductible $0 $0 $2,000 per / $4,000 per family $6,350 per / $250 per / $500 per family $0 $2,250 per / $4,500 per family $0 $500 per / $1,000 per family $2,250 per / $4,500 per family $50 per / $100 per family Some benefits are subject to a deductible. You are responsible for all charges up to the allowable amount until the deductible is met. At that point, you will be responsible for the copayment or coinsurance noted in the chart. In addition to the plans described in this guide, we also offer the following plans: Ultimate Native American, Preferred Native American, Enhanced Native American, Basic Native American, Basic for HSA Native American, and Native American 300 Subsidy. Visit blueshieldca.com for more information. * This Blue Shield plan must be purchased through Covered California, and your broker can help you with the process. All other Blue Shield medical plans displayed on this chart can be purchased through Blue Shield or Covered California. 2 For family coverage, s must satisfy their own deductible, unless a combination of three or more covered family members satisfies the family deductible. This satisfies the deductible for all covered family members for the remainder of the year.

3 Plan comparison chart (continued) Compare our plans to find the level of coverage you re looking for. 250 SUBSIDY* PLAN (SILVER) Office visit primary care doctor $40 BASIC PLAN (BRONZE) BASIC FOR HSA PLAN (BRONZE) GET COVERED PLAN (CATASTROPHIC) With participating providers, members pay 1 : $60 for first 3 visits per calendar year prior to deductible, then $60 after deductible 3 40% $0 for first 3 visits per calendar year prior to deductible, then $0 after deductible 3 Office visit specialist doctor $50 $70 40% 0% 40% Urgent care visit $80 year prior to deductible, $120 for first 3 visits per calendar then $120 after deductible 3 $0 for first 3 visits per calendar year prior to deductible, then $0 after deductible 3 Preventive health benefits $0 $0 $0 $0 Inpatient hospitalization 20% 30% 40% 0% Outpatient surgery 20% 30% 40% 0% Lab $40 30% 40% 0% X-ray $50 30% 40% 0% Emergency room services not resulting in admission $250 $300 40% 0% Maternity 20% 30% 40% 0% Generic drugs $19 $19 40% 0% Preferred brand drugs $30 $50 40% 0% Non-preferred brand drugs $50 $75 40% 0% Chiropractic Not covered Not covered Not covered Not covered Acupuncture (from a licensed acupuncturist) $40 $60 40% 0% Pediatric eye exam $0 $0 $0 $0 Pediatric eyeglasses $0 $0 $0 $0 Calendar-year medical deductible 2 Calendar-year out-of-pocket maximum (includes deductible) Calendar-year brand drug deductible $1,500 per / $3,000 per family $5,200 per / $10,400 per family $250 per / $500 per family $5,000 per / $10,000 per family $6,350 per / $4,500 per / $9,000 per family $6,350 per / $6,350 per / $6,350 per / $0 4 $0 4 $0 4 Some benefits are subject to a deductible. You are responsible for all charges up to the allowable amount until the deductible is met. At that point, you will be responsible for the copayment or coinsurance noted in the chart. In addition to the plans described in this guide, we also offer the following plans: Ultimate Native American, Preferred Native American, Enhanced Native American, Basic Native American, Basic for HSA Native American, and Native American 300 Subsidy. Visit blueshieldca.com for more information. * This Blue Shield plan must be purchased through Covered California, and your broker can help you with the process. All other Blue Shield medical plans displayed on this chart can be purchased through Blue Shield or Covered California. 2 For family coverage, s must satisfy their own deductible, unless a combination of three or more covered family members satisfies the family deductible. This satisfies the deductible for all covered family members for the remainder of the year. 3 Visit limit is a combination of any physician office visits, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visits. 4 Brand drugs are subject to the calendar-year medical deductible.

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

5 Get more value when you add family dental and vision coverage Total health includes oral and vision health. If you have children, their dental and vision needs can be covered by one of our pediatric dental plans, and the pediatric vision benefits we include in every medical plan. But what about you? For as little as $34.50 per month, you can get complete coverage by adding valuable family dental and vision coverage with your medical coverage.* We even offer a convenient standalone dental + vision package Specialty Duo SM,t to make it easy for you to get the best of both worlds with one simple purchase. All of our family dental plans can be purchased with or without a medical plan. DENTAL PPO 50/1250 DENTAL PLUS PPO 50/1250 DENTAL PPO 25/500 DENTAL PLUS PPO 25/500 SPECIALTY DUO DENTAL + VISION PACKAGE DENTAL PPO DENTAL HMO $0 DENTAL HMO Diagnostic and preventive services (includes but is not limited to cleanings, X-rays, initial and periodic oral examinations) Restorative services fillings (one surface resin composite) Oral surgery (includes but is not limited to extraction of erupted tooth or exposed root) as $24.70 as $27.90 as $21.30 as $23.20 as $47.90 With participating providers, members pay 1 : as $36.80 as $ % 0% 0% 0% $0 $0 $0 $0 20% 2 20% 2 20% 2 20% 2 $37 3 $37 3 $20 $18 as $ % 2 20% 2 20% 2 20% 2 $40 3 $40 3 $40 $34 Root canal (anterior root canal) 50% 4 50% 4 50% 4 50% 4 $156 3 $156 3 $175 $155 Crowns (porcelain/ceramic substrate) 50% 4 50% 4 50% 4 50% 4 $265 4 $265 4 $350 5 $300 5 Fixed bridges (pontic-cast high noble metal) Removable prosthetics (full upper or lower dentures) 50% 4 50% 4 50% 4 50% 4 $293 4 $293 4 $350 5 $ % 4 50% 4 50% 4 50% 4 $388 4 $388 4 $400 $400 Orthodontics Not covered 50% 4 (for children up to age 26 only; limitations apply 6 ) Not covered 50% 4 (for children up to age 26 only; limitations apply 7 ) Vision coverage (includes exam, frame, lens, and contacts benefits) Not covered Not covered Not covered Not covered See the family vision coverage section for details Not covered Not covered Not covered Calendar-year deductible 8 $50 per / $150 per family $50 per / $150 per family $25 per / $75 per family $25 per / $75 per family $50 per $50 per $0 $0 Calendar-year benefit maximum $1,250 per $1,250 per $500 per $500 per $1,000 per $1,000 per None None This chart is an overview of benefits. For additional benefit information, cost for services, waiting periods, and exclusions and limitations, please see the Summary Guide and Important Legal Information booklets. The Enhanced Dental PPO 50/1250, Enhanced Dental Plus PPO 50/1250, Enhanced Dental PPO 25/500, Enhanced Dental Plus PPO 25/500, and Enhanced Dental HMO $0 plans are pending regulatory approval. * Rate is for a 21-year-old enrolled in the Enhanced Dental HMO $0 and Ultimate Vision 15/25/150 plans. t Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Specialty Duo is pending regulatory approval. Rate is for members ages 0 through There is a six-month waiting period for these services. 3 There is a three-month waiting period for these services. 4 There is a 12-month waiting period for these services. 5 If precious metals are used, member will be charged at the dentist s cost. For Dental HMO, porcelain on molar teeth is subject to an additional charge of $ There is a $100 deductible for orthodontia, a $500 annual maximum benefit per child per year, and a $1,000 maximum per child per lifetime. 7 There is a $50 deductible for orthodontia, a $250 annual maximum benefit per child per year, and a $500 maximum per child per lifetime. 8 Applies to all services except diagnostic and preventive services. See endnotes 6 and 7 above for deductible requirements specific to orthodontics.

6 Family vision coverage Keep an eye on your vision health with a Blue Shield vision plan. Ultimate Vision 15/25/150* is a comprehensive vision plan that features a $150 frame allowance, and ULTIMATE VISION 15/25/150 as $21.00 t SPECIALTY DUO DENTAL + VISION PACKAGE as $47.90 t Allowance and copays with participating providers 1 : Eye exam (every 12 months) $15 copay $0 copay Materials copay $25 copay $25 copay Frames Lenses Standard single vision, lined bifocal or lined trifocal with scratch coating Lens options and treatments Polycarbonate lenses (only for dependent children) $150 allowance (every 12 months) $100 allowance (every 24 months) $0 copay $0 copay $100 allowance $100 allowance Polycarbonate lenses $160 allowance Not covered Progressive lenses $115 allowance Not covered Anti-reflective lens coating $140 allowance Not covered Contact lenses 2 Medically necessary $25 copay $25 copay Elective (cosmetic or convenience) $120 allowance $120 allowance Diabetes management referral $0 copay $0 copay Dental benefits (includes coverage for preventive, diagnostic, minor services, and major services) Specialty Duo offers the convenience of dental and vision coverage in a single package. Both plans can be purchased with or without a medical plan. None See the family dental plans section for details Deductible $0 $0 Individual term life insurance Facing financial burdens after the loss of a loved one can be overwhelming, and having life insurance helps. Individual term life insurance plans from Blue Shield Life can help safeguard the future of the significant people in your life your spouse, partner, or children by providing critical financial protection that can be used to cover living expenses, college education costs, mortgage payments, and more. Take a step toward safeguarding the financial future of those you care about by applying for life insurance coverage from Blue Shield Life. We offer the financial protection and security of $10,000, $30,000, $60,000, $90,000, and $100,000 in term life insurance with low monthly rates based on your age. Age range $10,000 $30,000 $60,000 $90,000 $100,000 Available coverage amounts* 1 to 18 t $1.95 $2.95 N/A N/A N/A 19 to 29 $2.75 $5.35 $9.25 $13.15 $ to 39 $3.05 $6.25 $11.05 $15.85 $ to 49 $5.85 $14.65 $27.85 $41.05 $ to 59 $13.85 $38.65 $75.85 $ $ to 64 $20.45 $58.45 $ $ $ Coverage is available to all s, ages 1 to 64, with or without a Blue Shield health plan. Simply complete and submit the Application for Individual Term Life Insurance Coverage for consideration. Download the application at blueshieldca.com/bsca/find-a-plan/ life-insurance-plans or call your broker today. * Individual term life insurance is available to applicants ages 1 to 64. All plans terminate at age 65. t Those under age 19 are not eligible for $60,000, $90,000, or $100,000 amounts of coverage. This chart is an overview of benefits. For additional benefit information, cost for services, waiting periods, and exclusions and limitations, please see the Summary Guide and Important Legal Information booklets. * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Ultimate Vision 15/25/150 is pending regulatory approval. t Rate is for members ages 0 through Participating providers accept Blue Shield s allowable amounts as payment-in-full for covered services. There is a 90-day waiting period for all vision benefits.! i 2 Contact lens may be selected in lieu of eyeglasses. It s easy to apply! Get the valuable coverage you need with a Blue Shield plan. Call your broker today! You can also visit blueshieldca.com/findaplan. Blue Shield of California is an independent member of the Blue Shield Association A12179-OL-REV (1/14) Covered California is a registered trademark of the State of California. blueshieldca.com