Your Summary of Benefits Premier PPO

Transcription

1 Your Summary of Benefits Premier PPO Premier PPO 250/15/10 This Summary of Benefits is a brief overview of your plan's benefits only. The benefits listed are for both in state and out of state members, there may be differences in benefits depending on where you reside. For more detailed information about the benefits in your plan, please refer to your Certificate of Insurance or Certificate or Evidence of Coverage (EOC), which explains the full range of covered services, as well as any exclusions and limitations for your plan. In addition to dollar and percentage copays, members are responsible for deductibles, as described below. Please review the deductible information below to know if a deductible applies to a specific covered service. Certain Covered Services have maximum visit and/or day limits per year. The number of visits and/or days allowed for these services will begin accumulating on the first visit and/or day, regardless of whether your Deductible has been met. Members are also responsible for all costs over the plan maximums. Plan maximums & other important information appear in italics. Benefits aresubject to all terms, conditions, limitations, and exclusions of the Policy. Subject to Utilization Review Certain services are subject to the utilization review program. Before scheduling services, the member must make sure utilization review is obtained. If utilization review is not obtained, benefits may be reduced or not paid, according to the plan. Explanation of Maximum Allowed Amount Maximum Allowed Amount is the total reimbursement payable under the plan for covered services received from Participating and Non-Participating Providers. It is the payment towards the services billed by a provider combined with any applicable deductible, copayment or coinsurance. PPO Providers The rate the provider has agreed to accept as reimbursement for covered services. Members are not responsible for the difference between the provider's usual charges & the maximum allowed amount. Non-PPO Providers For non-emergency care, reimbursement amount is based on: an Anthem Blue Cross rate or fee schedule, a rate negotiated with the provider, information from a third party vendor, or billed charges. Members are responsible for the difference between the provider's usual charges & the maximum allowed amount. For Calendar Medical year Emergency deductible care rendered (Cross application by a Non-Participating applies) Provider or Non-Contracting $250/member; Hospital, maximum reimbursement of three separate is based deductibles/family on the reasonable and customary value. Members may be responsible for any amount in excess of the reasonable and customary value. Deductible for non-anthem Blue Cross PPO hospital or residential treatment using Non-PPO center and Other Health Care Providers, members are responsible for any difference between the covered expense & actual charges, as $500/admission (waived for emergency admission) When well as any deductible & percentage copay. Calendar Deductible year for deductible non-anthem for Blue all providers Cross PPO hospital or residential treatment center if utilization review not obtained $250/member; $500/admission $750/family (waived for emergency admission) Additional deductible for non-anthem Blue Cross PPO hospital or $500/admission (waived for emergency admission) residential Deductible treatment for emergency center room if utilization services review not obtained $100/visit (waived if admitted directly from ER) Deductible Annual Out-of-Pocket for emergency Maximums room services $100/visit (waived if admitted directly from ER) PPO Providers & Other Health Care Providers $3,500/insured person/year; $7,000/insured family/year Annual Non-PPO Out-of-Pocket Providers Maximums (no cross application) $10,000/insured person/year; $20,000/insured family/year PPO Providers & Other Health Care Providers The following do not apply to out-of-pocket maximums: deductibles listed above; $2,500/member; non-covered $5,000/family expense. After an insured person reaches the out-ofpocket Non-PPO maximum, Providers the insured person no longer pays percentage copays for $6,500/member; the remainder of $13,000/family the year. However, insured person remains responsible for deductibles listed above; for non-ppo providers & other health care providers, costs in excess of the covered expense; amounts related to a The transplant following unrelated do not apply donor to search. out-of-pocket maximums: non-covered expense. After a member reaches the out-of-pocket maximum, the member remains responsible for costs in excess of the covered expense. Lifetime Maximum $5,000,000/insured person Lifetime Maximum Unlimited Covered Services PPO: Per Member Copay Non-PPO: Per Insured Member Person Copay Covered Services PPO: Per Insured Person Copay Copay Preventive Care Services Adult Preventive Services (including mammograms, Pap Preventive smears, prostate Care Services cancer including*, screenings physical & colorectal exams, preventive screenings (including screenings for cancer, HPV, diabetes, cancer cholesterol, 30% 50% blood screenings) pressure, hearing and vision, immunizations, health education, (deductible waived) (deductible waived) intervention services, HIV testing), and additional preventive care for women Well Baby provided & Well-Child for in the Care guidelines for Dependent supported by Children the Health Resources } Routine and physical Services examinations Administration. (birth through age six) $30/exam (deductible waived) 50% *This list is not exhaustive. This benefit includes all Preventive Care (benefit limited to $20/exam) Services } Immunizations required by (birth federal through and state age six) law. No copay 50% (deductible No copay waived) (benefit 30% (deductible waived) limited to $12/ immunization) Physician Medical Services Physical Office & Exams home visits for Insured (includes Persons retail health Ages clinic Seven & online & Older visit) $15/visit 30% } Routine physical exams, immunizations, diagnostic X-ray & lab for $30/exam (deductible (deductible waived) waived) Not covered Hospital routine physical & skilled exam nursing facility visits 10% 30% Physician Surgeon Medical & surgical Services assistant; anesthesiologist or anesthetist 10% 30% } Drugs Office administered & home visits by a medical provider (certain drugs are subject $30/visit 10% (deductible waived) 2 50% 30% to utilization review) (deductible waived) } Diabetes Hospital Education & skilled nursing Programs facility (requires visits physician supervision) 30% 50% } Surgeon & surgical assistant; anesthesiologist or anesthetist CONTINUED ON NEXT PAGE 30% 50%

2 Covered Services PPO: Per Member Copay Non-PPO: Per Member Copay Teach members & their families about the disease process, the $15/visit 30% daily management of diabetic therapy & self-management training (deductible waived) Physical Therapy, Physical Medicine & Occupational Therapy, 10% 30% including Chiropractic Services (limited to 24 visits/calendar year; additional visits may be authorized) Speech Therapy Outpatient speech therapy 10% 30% Acupuncture Services for the treatment of disease, illness or injury (limited 12 10% 30% visits/calendar year) Diagnostic X-ray & Lab Other diagnostic x-ray & lab 10% 30% Advanced Imaging (subject to utilization review) 10% 30% (benefit limited to $800/procedure) Urgent Care (physician services) $15/visit (deductible waived) 30% Emergency Care Emergency room services & supplies ($100 deductible waived if 10% 10% admitted inpatient) Physician services 10% 10% Hospital Medical Services (subject to utilization review for inpatient and certain outpatient services; waived for emergency admissions) Semi-private or private room, medically necessary services & supplies Outpatient medical care, surgical services & supplies (hospital care other than emergency room care) Skilled Nursing Facility (subject to utilization review) Semi-private room, services & supplies (limited to 100 days/calendar year) Related Outpatient Medical Services & Supplies Ground or air ambulance transportation, services & disposable supplies (air ambulance in a non-medical emergency is subject to 10% 30% 10% 30% 10% 30% 10% In an emergency or with an authorized referral: 10%; Non-emergency: 30% pre-service review and benefit limited to $50,000 for non-ppo) Blood transfusions, blood processing & the cost of unreplaced 20% 20% blood & blood products Autologous blood (self-donated blood collection, testing, processing & storage for planned surgery) 20% 20% Ambulatory Surgical Centers (certain surgeries are subject to utilization review) Outpatient surgery, services & supplies 10% 30% (benefit limited to $350/admit) Pregnancy & Maternity Care Physician office visits $15/visit (deductible waived) 30% Prescription drug for elective abortion (mifepristone) 10% 30% Normal delivery, cesarean section, complications of pregnancy & abortion. Refer to the Physician & Hospital Medical Services benefits for both inpatient and outpatient hospital coverage. Mental or Nervous Disorders and Substance Abuse Inpatient Care Facility-based care (subject to utilization review; waived for 10% 30% emergency admissions) Inpatient physician visits 10% 30% Outpatient Care Facility-based care (subject to utilization review; waived for emergency admissions) Outpatient physician visits (Behavioral Health treatment for Autism or Pervasive Development disorders require pre-service review) Durable Medical Equipment (may be subject to utilization review) CONTINUED ON NEXT PAGE 10% 30% $15/visit 30% (deductible waived)

3 Covered Services PPO: Per Member Copay Non-PPO: Per Member Copay Rental or purchase of DME (breast pump and supplies are covered under preventive care at no charge for in-network) Home Health Care (subject to utilization review) Services & supplies from a home health agency (limited to 100 visits/calendar year, one visit by a home health aide equals four hours or less) Home Infusion Therapy (subject to utilization review) Includes medication, ancillary services & supplies; caregiver training & visits by provider to monitor therapy; durable medical equipment; lab services Hemodialysis 10% 30% 10% 30% 10% 30% (benefit limited to $600/day) Outpatient hemodialysis services & supplies 10% 30% (benefit limited to $350/visit for free standing hemodialysis center) Hospice Care Inpatient or outpatient services; family bereavement services No copay 30% Bariatric Surgery (subject to utilization review; covered only when performed at a Centers of Medical Excellence [CME] for California; Blue Distinction Centers for Specialty Care [BDCSC] for out of California) Inpatient services provided in connection with medically necessary surgery for weight loss, only for morbid obesity Travel expenses for an authorized, specified surgery (recipient & companion transportation limited to $3,000 per surgery) Organ & Tissue Transplants (subject to utilization review; specified transplants covered only when performed at Centers of Medical Excellence [CME] for California; Blue Distinction Centers for Specialty Care [BDCSC] and CME for out of California) Inpatient services provided in connection with non-investigative organ or tissue transplants Transplant travel expense for an authorized, specified transplant (recipient & companion transportation limited to $10,000 per transplant) Unrelated donor search, limited to $30,000 per transplant Prosthetic Devices Coverage for breast prostheses; prosthetic devices to restore a method of speaking; surgical implants; artificial limbs or eyes; the first pair of contact lenses or eyeglasses when required as a result of eye surgery; & therapeutic shoes & inserts for members with diabetes (deductible waived) 10% Not covered No copay (deductible waived) Not covered 10% Not covered No copay (deductible waived) 10% 30% Not covered Certain types of physicians may not be represented in the PPO network in the state where the member receives services. If such physician is not available in the service area, the member's copay is the same as for PPO (with and without pre-notification, if applicable). Member is responsible for applicable copays, deductibles and charges which exceed covered expense. In addition to the benefits described above, coverage may include additional benefits, depending upon the member's home state. The benefits provided in this summary are subject to federal and California laws. There are some states that require more generous benefits be provided to their residents, even if the master policy was not issued in their state. If the member's state has such requirements, we will adjust the benefits to meet the requirements. This Summary of Benefits has been updated to comply with federal and state requirements, including applicable provisions of the recently enacted federal health care reform laws. As we receive additional guidance and clarification on the new health care reform laws from the U.S. Department of Health and Human Services, Department of Labor and Internal Revenue Service, we may be required to make additional changes to this summary of benefits. This proposed benefit summary is subject to the approval of the California Department of Insurance and the California Department of Managed Health Care. The dollar copay applies only to the visit itself. An additional copay applies for any services performed in office (i.e., X-ray, lab, surgery), after any applicable deductible. These providers may not be represented in the PPO network in the state where the member receives services. Exception: If service is performed at a Centers of Medical Excellence [CME] for California or Blue Distinction Centers for Speciality Care [BDCSC] for out of California, the services will be covered same as the PPO (in-network) benefit.

4 Exclusions and Limitations Not Medically Necessary. Services or supplies that are not medically necessary, as defined. Experimental or Investigative. Any experimental or investigative procedure or medication. But, if member is denied benefits because it is determined that the requested treatment is experimental or investigative, the member may request an independent medical review, as described in the Certificate. Outside the United States. Services or supplies furnished and billed by a provider outside the United States, unless such services or supplies are furnished in connection with urgent care or an emergency. Crime or Nuclear Energy. Conditions that result from (1) the member's commission of or attempt to commit a felony, as long as any injuries are not a result of a medical condition or an act of domestic violence; or (2) any release of nuclear energy, whether or not the result of war, when government funds are available for the treatment of illness or injury arising from the release of nuclear energy. Not Covered. Services received before the member's effective date. Services received after the member's coverage ends, except as specified as covered in the Certificate. Excess Amounts. Any amounts in excess of covered expense or any medical benefit maximum. Work-Related. Work-related conditions if benefits are recovered or can be recovered, either by adjudication, settlement or otherwise, under any workers' compensation, employer's liability law or occupational disease law, whether or not the member claims those benefits. If there is a dispute of substantial uncertainty as to whether benefits may be recovered for those conditions pursuant to workers' compensation, we will provide the benefits of this plan for such conditions, subject to a right of recovery and reimbursement under California Labor Code Section 4903, as specified as covered in the Certificate. Government Treatment. Any services the member actually received that were provided by a local, state or federal government agency, except when payment under this plan is expressly required by federal or state law. We will not cover payment for these services if the member is not required to pay for them or they are given to the member for free. Services of Relatives. Professional services received from a person living in the member's home or who is related to the member by blood or marriage, except as specified as covered in the Certificate. Voluntary Payment. Services for which the member has no legal obligation to pay, or for which no charge would be made in the absence of insurance coverage or other health plan coverage, except services received at a non-governmental charitable research hospital. Such a hospital must meet the following guidelines:1. it must be internationally known as being devoted mainly to medical research;2. at least 10% of its yearly budget must be spent on research not directly related to patient care;3. at least one-third of its gross income must come from donations or grants other than gifts or payments for patient care;4. it must accept patients who are unable to pay; and5. two-thirds of its patients must have conditions directly related to the hospital's research. Not Specifically Listed. Services not specifically listed in the plan as covered services. Private Contracts. Services or supplies provided pursuant to a private contract between the member and a provider, for which reimbursement under Medicare program is prohibited, as specified in Section 1802 (42 U.S.C. 1395a) of Title XVIII of the Social Security Act. Inpatient Diagnostic Tests. Inpatient room and board charges in connection with a hospital stay primarily for diagnostic tests which could have been performed safely on an outpatient basis. Mental or Nervous Disorders. Academic or educational testing, counseling, and remediation. Mental or nervous disorders or substance abuse, including rehabilitative care in relation to these conditions, except as specified as covered in the Certificate. Nicotine Use. Smoking cessation programs or treatment of nicotine or tobacco use if the program is not affiliated with Anthem. Smoking cessation drugs except as specified as covered in the EOC or Certificate. Orthodontia. Braces, other orthodontic appliances or orthodontic services. Dental Services or Supplies. For dental treatment, regardless of origin or cause, except as specified below. "Dental treatment" includes but is not limited to preventative care and fluoride treatments; dental x rays, supplies, appliances, dental implants and all associated expenses; diagnosis and treatment related to the teeth, jawbones or gums, including but not limited to: 1. Extraction, restoration, and replacement of teeth; 2. Services to improve dental clinical outcomes. This exclusion does not apply to the following: 1. Services which we are required by law to cover; 2. Services specified as covered in this booklet; 3. Dental services to prepare the mouth for radiation therapy to treat head and/or neck cancer. Hearing Aids or Tests. Hearing aids and routine hearing tests, except as specified as covered in the Certificate. Optometric Services or Supplies. Optometric services, eye exercises including orthoptics. Routine eye exams and routine eye refractions, as specified as covered in the Certificate. Eyeglasses or contact lenses, except as specified as covered in the Certificate. Outpatient Occupational Therapy. Outpatient occupational therapy, except by a home health agency, hospice, or home infusion therapy provider, as specified as covered in the Certificate. Outpatient Speech Therapy. Outpatient speech therapy, except as specified as covered in the Certificate. Cosmetic Surgery. Cosmetic surgery or other services performed solely for beautification or to alter or reshape normal (including aged) structures or tissues of the body to improve appearance. This exclusion does not apply to reconstructive surgery (that is, surgery performed to correct deformities caused by congenital or developmental abnormalities, illness, or injury for the purpose of improving bodily function or symptomatology or to create a normal appearance), including surgery performed to restore symmetry following mastectomy. Cosmetic surgery does not become reconstructive surgery because of psychological or psychiatric reasons. Commercial Weight Loss Programs. Weight loss programs, whether or not they are pursued under medical or physician supervision, unless specifically listed as covered in this plan. This exclusion includes, but is not limited to, commercial weight loss programs (Weight Watchers, Jenny Craig, LA Weight Loss) and fasting programs. This exclusion does not apply to medically necessary treatments for morbid obesity or dietary evaluations and counseling, and behavioral modification programs for the treatment of anorexia nervosa or bulimia nervosa. Surgical treatment for morbid obesity is covered as described in the Certificate. Sterilization Reversal. Infertility Treatment. Any services or supplies furnished in connection with the diagnosis and treatment of infertility, including, but not limited to diagnostic tests, medication, surgery, artificial insemination, in vitro fertilization, sterilization reversal and gamete intrafallopian transfer. Surrogate Mother Services. For any services or supplies provided to a person not covered under the plan in connection with a surrogate pregnancy (including, but not limited to, the bearing of a child by another woman for an infertile couple). Orthopedic shoes and shoe inserts. This exclusion does not apply to orthopedic footwear used as an integral part of a brace, shoe inserts that are custom molded to the patient, or therapeutic shoes and inserts designed to treat foot complications due to diabetes, as specifically stated in the EOC/Certificate. Air Conditioners. Air purifiers, air conditioners or humidifiers. Custodial Care or Rest Cures. Inpatient room and board charges in connection with a hospital stay primarily for environmental change or physical therapy. Services provided by a rest home, a home for the aged, a nursing home or any similar facility. Services provided by a skilled nursing facility or custodial care or rest cures, except as specified as covered in the Certificate. Clinical Trials - Services and supplies in connection with clinical trials, except as specified as covered in the Certificate or EOC. Health Club Memberships. Health club memberships, exercise equipment, charges from a physical fitness instructor or personal trainer, or any other charges for activities, equipment or facilities used for developing or maintaining physical fitness, even if ordered by a physician. This exclusion also applies to health spas. Personal Items. Any supplies for comfort, hygiene or beautification. Education or Counseling. Educational services or nutritional counseling, except as specified as covered in the Certificate. This exclusion does not apply to counseling for the treatment of anorexia nervosa or bulimia nervosa. Food or Dietary Supplements. Nutritional and/or dietary supplements, except as provided in this plan or as required by law. This exclusion includes, but is not limited to, those nutritional formulas and dietary supplements that can be purchased over the counter, which by law do not requirement either a written prescription or dispensing by a licensed pharmacist. Telephone and Facsimile Machine Consultations. Consultations provided by telephone or facsimile machine. Routine Exams or Tests. Routine physical exams or tests which do not directly treat an actual illness, injury or condition, including those required by employment or government authority, except as specified as covered in the Certificate. Acupuncture. Acupuncture treatment, except as specified as covered in the Certificate. Acupressure or massage to control pain, treat illness or promote health by applying pressure to one or more specific areas of the body based on dermatomes or acupuncture points. Eye Surgery for Refractive Defects. Any eye surgery solely or primarily for the purpose of correcting refractive defects of the eye such as nearsightedness (myopia) and/or astigmatism. Contact lenses and eyeglasses required as a result of this surgery. Physical Therapy or Physical Medicine. Services of a physician for physical therapy or physical medicine, except when provided during a covered inpatient confinement or as specified as covered in the Certificate. Outpatient Prescription Drugs and Medications. Outpatient prescription drugs or medications and insulin, except as specified as covered in the Certificate. Any non-prescription, over-the-counter patent or proprietary drug or medicine. Cosmetics, health or beauty aids. Specialty Pharmacy Drugs. Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but, which are obtained from a retail pharmacy, are not covered by this plan. Member will have to pay the full cost of the specialty pharmacy drugs obtained from a retail pharmacy that should have been obtained from the specialty pharmacy program. Contraceptive Devices. Contraceptive devices prescribed for birth control except as specified as covered in the Certificate. Diabetic Supplies. Prescription and non-prescription diabetic supplies except as specified as covered in the Certificate. Private Duty Nursing. Private duty nursing services. Lifestyle Programs. Programs to alter one's lifestyle which may include but are not limited to diet, exercise, imagery or nutrition. This exclusion will not apply to cardiac rehabilitation programs approved by us. Varicose Vein Treatment. Treatment of varicose veins or telangiectatic dermal veins (spider veins) by any method (including sclerotherapy or other surgeries) when services are rendered for cosmetic purposes. Wigs. Third Party Liability Anthem Blue Cross Life and Health Insurance Company is entitled to reimbursement of benefits paid if the member recovers damages from a legally liable third party. Coordination of Benefits The benefits of this plan may be reduced if the member has any other group health or dental coverage so that the services received from all group coverages do not exceed 100% of the covered expense. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. anthem.com/ca Anthem Blue Cross/Anthem Blue Cross Life and Health Insurance Company;(P-NP) Effective Printed 09/2013 LP

5 Anthem BlueCross Premier PPO 250/15/10 / $10/$25/$45/20% Summary of Benefits and Coverage: What this Plan Covers & What it Costs Coverage Period: 06/01/ /31/2015 Coverage For: Individual/Family Plan Type: PPO This is only a summary. If you want more detail about your coverage and costs, you can get the complete terms in the policy or plan document at or by calling Important Questions Answers Why this Matters: What is the overall deductible? $250 single / $750 family for In- Network Provider $250 single / $750 family for Non-Network Provider Does not apply to Preventive Care, Office Visit Copayments, Hospice and Prescription Drugs In-Network Provider and Non- Network Provider deductibles are combined. Satisfying one helps satisfy the other. You must pay all the costs up to the deductible amount before this health insurance plan begins to pay for covered services you use. Check your policy to see when the deductible starts over (usually, but not always, January 1st.) See the chart starting on page 3 for how much you pay for covered services after you meet the deductible. Are there other deductibles for specific services? Yes; $500 per member for Additional deductible for non- Anthem Blue Cross PPO hospital or residential treatment center if utilization review not obtained., and $100 per member for Deductible for emergency room services, waived if admitted.. You must pay all the costs for these services up to the specific deductible amount before this plan begins to pay for these services. Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. CA LG Premier PPO 250/15/10 $10/$25/$45/20% 1/14 Page 1 of 11

6 Important Questions Answers Why this Matters: Is there an out-of-pocket limit on my expenses? What is not included in the out-of-pocket limit? Is there an overall annual limit on what the insurer pays? Does this plan use a network of providers? Do I need a referral to see a specialist? Are there services this plan doesn't cover? Yes; In-Network Provider Single: $2500, Family: $5000 Non-Network Provider Single: $6500, Family: $13000 In- Network Provider and Non- Network Provider out-of-pocket are separate and do not count towards each other. Balance-Billed Charges, Health Care This Plan Doesn't Cover, Premiums, Costs Related to Prescription Drugs Covered Under the Prescription Drug Plan. No. This policy has no overall annual limit on the amount it will pay each year. Yes. See or call for a list of participating providers. No, you do not need a referral to see a specialist. Yes. The out-of-pocket limit is the most you could pay during a policy period for your share of the cost of covered services. This limit helps you plan for health care expenses. Even though you pay these expenses, they don't count toward the out-of-pocket limit. The chart starting on page 3 describes any limits on what the insurer will pay for specific covered services, such as office visits. If you use an in-network doctor or other health care provider, this plan will pay some or all of the costs of covered services. Plans use the terms in-network, preferred, or participating to refer to providers in their network. You can see the specialist you choose without permission from this plan. Some of the services this plan doesn t cover are listed on page 7. See your policy or plan document for additional information about excluded services. Page 2 of 11

7 Co-payments are fixed dollar amounts (for example, $15) you pay for covered health care, usually when you receive the service. Co-insurance is your share of the costs of a covered service, calculated as a percent of the allowed amount for the service. For example, if the plan's allowed amount for an overnight hospital stay is $1,000, your co-insurance payment of 20% would be $200. This may change if you haven't met your deductible. The amount the plan pays for covered services is based on the allowed amount. If an out-of-network provider charges more than the allowed amount, you may have to pay the difference. For example, if an out-of-network hospital charges $1,500 for an overnight stay and the allowed amount is $1,000, you may have to pay the $500 difference. (This is called balance billing.) This plan may encourage you to use In-Network Provider by charging you lower deductibles, co-payments and co-insurance amounts. Common Medical Event If you visit a health care provider's office or clinic If you have a test Services You May Need Primary care visit to treat an injury or illness Your Cost If You Use a In- Network Provider Your Cost If You Use a Non- Network Provider Limitations & Exceptions $15 copay per visit 30% coinsurance none Specialist visit $15 copay per visit 30% coinsurance none Other practitioner office visit Preventive care/screening/ immunizations Diagnostic test (x-ray, blood work) Chiropractor 10% coinsurance Acupuncturist 10% coinsurance Chiropractor 30% coinsurance Acupuncturist 30% coinsurance Chiropractor Coverage is limited to 24 visits per year. Services from In-Network and Non-Network providers count towards your limit.. Chiropractic visits count towards your physical and occupational therapy limit. Acupuncturist Coverage is limited to a total of 12 visits, In- Network Provider and Non-Network Provider combined per year. No charge 30% coinsurance none Lab - Office 10% coinsurance X-Ray - Office 10% coinsurance Lab - Office 30% coinsurance X-Ray - Office 30% coinsurance none Page 3 of 11

8 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at pharmacyinformation/ If you have outpatient Surgery Services You May Need Your Cost If You Use a In- Network Provider Your Cost If You Use a Non- Network Provider Imaging (CT/PET scans, MRIs) 10% coinsurance 30% coinsurance Tier 1 Typically Generic Tier 2 Typically Preferred/Formulary Brand Tier 3 Typically Non-preferred/ non-formulary Drugs Tier 4 Typically Specialty Drugs Facility Fee (e.g., ambulatory surgery center) $10 copay/ prescription (retail and mail order) $25 copay/ prescription (retail only) and $50 copay/prescription (mail order only) $45 copay/ prescription (retail only) and $90 copay/prescription (mail order only) 20% coinsurance (retail only) with $150 max and 20% coinsurance (mail order only) with $300 max 50% coinsurance 50% coinsurance 50% coinsurance 50% coinsurance 10% coinsurance 30% coinsurance Limitations & Exceptions Coverage is limited to $800 per test to Non- Network Provider. For Out of network: Member pays the retail pharmacy copay plus 50% Covers up to a 30 day supply (retail pharmacy), Covers up to a 90 day supply (mail order program) For Out of network: Member pays the retail pharmacy copay plus 50% Covers up to a 30 day supply (retail pharmacy), Covers up to a 90 day supply (mail order program) Certain drugs require preauthorization approval to obtain coverage. For Out of network: Member pays the retail pharmacy copay plus 50% Covers up to a 30 day supply (retail pharmacy), Covers up to a 90 day supply (mail order program) Classified specialty drugs must be obtained through our Specialty Pharmacy Program and are subject to the terms of the program. For Out of network: Member pays the retail pharmacy copay plus 50% $3500 annual out-of-pocket limit per member Coverage is limited to $350 / visitfor Non- Network Ambulatory Surgery Center. Physician/Surgeon Fees 10% coinsurance 30% coinsurance none Page 4 of 11

9 Common Medical Event If you need immediate medical attention If you have a hospital stay If you have mental health, behavioral health, or substance abuse needs Services You May Need Your Cost If You Use a In- Network Provider Your Cost If You Use a Non- Network Provider Emergency Room Services 10% coinsurance 10% coinsurance Emergency Medical Transportation Limitations & Exceptions Additional deductible of $100 applies, waived if admitted in patient. This is for the hospital/facility charge only. The ER physician charge may be separate 10% coinsurance 10% coinsurance none Urgent Care $15 copay per visit 30% coinsurance Facility Fee (e.g., hospital room) 10% coinsurance 30% coinsurance Costs may vary by site of service. You should refer to your formal contract of coverage for details. Failure to obtain preauthorization may result in non-coverage or an additional $500 copayment for non-participating providers, waived for emergency admissions. Physician/surgeon fee 10% coinsurance 30% coinsurance none Mental/Behavioral health outpatient services Mental/Behavioral health inpatient services Substance use disorder outpatient services Mental/Behavioral Health Office Visit $15 copay per visit Mental/Behavioral Health Facility Visit - Facility Charges 10% coinsurance Mental/Behavioral Health Office Visit 30% coinsurance Mental/Behavioral Health Facility Visit - Facility Charges 30% coinsurance 10% coinsurance 30% coinsurance Substance Abuse Office Visit $15 copay per visit Substance Abuse Facility Visit - Facility Charges 10% coinsurance Substance Abuse Office Visit 30% coinsurance Substance Abuse Facility Visit - Facility Charges 30% coinsurance none This is for facility professional services only. Please refer to hospital stay for facility fee none Page 5 of 11

10 Common Medical Event Services You May Need Substance use disorder inpatient services Your Cost If You Use a In- Network Provider Your Cost If You Use a Non- Network Provider 10% coinsurance 30% coinsurance If you are pregnant Prenatal and postnatal care 10% coinsurance 30% coinsurance If you need help recovering or have other special health needs If your child needs dental or eye care Limitations & Exceptions This is for facility professional services only. Please refer to hospital stay for facility fee. Your doctor s charges for delivery are part of prenatal and postnatal care. Delivery and all inpatient services 10% coinsurance 30% coinsurance none Home Health Care 10% coinsurance 30% coinsurance Rehabilitation Services 10% coinsurance 30% coinsurance Habilitation Services 10% coinsurance 30% coinsurance Skilled Nursing Care 10% coinsurance 30% coinsurance Coverage is limited to a total of 100 visits, In- Network Provider and Non-Network Provider combined per year. Services from In-Network Provider and Non- Network Provider count towards your limit. Coverage is limited to 24 visits per year. Services from In-Network and Non-Network providers count towards your limit.. Costs may vary by site of service. You should refer to your formal contract of coverage for details. Chiropractic visits count towards your physical and occupational therapy limit. Habilitation visits count towards your rehabilitation limit Coverage is limited to a total of 100 days, In- Network Provider and Non-Network Provider combined per year. Durable medical equipment 10% coinsurance 30% coinsurance none Hospice service No charge 30% coinsurance none Eye exam Not covered Not covered none Glasses Not covered Not covered none Dental check-up Not covered Not covered none Page 6 of 11

11 Excluded Services & Other Covered Services: Services Your Plan Does NOT Cover (This isn't a complete list. Check your policy or plan document for other excluded services.) Cosmetic surgery Dental care (adult) Hearing aids Infertility treatment Long- term care Most coverage provided outside the United States. See Private-duty nursing Routine eye care (adult) Routine foot care unless you have been diagnosed with diabetes. Consult your formal contract of coverage. Weight loss programs Other Covered Services (This isn't a complete list. Check your policy or plan document for other covered services and your costs for these services.) Acupuncture Bariatric surgery for morbid obesity Chiropractic care Page 7 of 11

12 Your Rights to Continue Coverage: If you lose coverage under the plan, then, depending upon the circumstances, Federal and State laws may provide protections that allow you to keep health coverage. Any such rights may be limited in duration and will require you to pay a premium, which may be significantly higher than the premium you pay while covered under the plan. Other limitations on your rights to continue coverage may also apply. For more information on your rights to continue coverage, contact the plan at You may also contact your state insurance department, the Department of Labor s Employee Benefits Security Administration EBSA (3272) Your Grievance and Appeals Rights: If you have a complaint or are dissatisfied with a denial of coverage for claims under your plan, you may be able to appeal or file a grievance. For questions about your rights, this notice, or assistance, you can contact: Anthem BlueCross ATTN: Appeals P.O. Box 4310 Woodland Hills, CA Or Contact: Department of Labor s Employee Benefits Security Administration at EBSA(3272) or Does this Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as minimum essential coverage. This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This health coverage does meet the minimum value standard for the benefits it provides. Page 8 of 11

13 To see examples of how this plan might cover costs for a sample medical situation, see the next page. Page 9 of 11

14 About These Coverage Examples: These examples show how this plan might cover medical care in given situations. Use these examples to see, in general, how much financial protection a sample patient might get if they are covered under different plans. This is not a cost estimator. Don t use these examples to estimate your actual costs under this plan. The actual care you receive will be different from these examples, and the cost of that care will also be different. See the next page for important information about these examples. Having a baby (normal delivery) Amount owed to providers: $7,540 Plan pays: $6,420 Patient pays: $1,120 Sample care costs: Hospital charges (mother) $2,700 Routine obstetric care $2,100 Hospital charges (baby) $900 Anesthesia $900 Laboratory tests $500 Prescriptions $200 Radiology $200 Vaccines, other preventive $40 Total $7,540 Patient pays: Total Deductibles $250 Co-pays $20 Co-insurance $700 Limits or exclusions $150 Total $1,120 Managing type 2 diabetes (routine maintenance of a well-controlled condition) Amount owed to providers: $5,400 Plan pays: $4,400 Patient pays: $1,000 Sample care costs: Prescriptions $2,900 Medical Equipment and Supplies $1,300 Office Visits and Procedures $700 Education $300 Laboratory tests $100 Vaccines, other preventive $100 Total $5,400 Patient pays: Total Deductibles $250 Co-pays $550 Co-insurance $120 Limits or exclusions $80 Total $1,000 Page 10 of 11

15 Questions and answers about the Coverage Examples: What are some of the assumptions behind the Coverage Examples? Costs don't include premiums. Sample care costs are based on national averages supplied by the U.S. Department of Health and Human Services, and aren't specific to a particular geographic area or health plan. The patient's condition was not an excluded or preexisting condition. All services and treatments started and ended in the same coverage period. There are no other medical expenses for any member covered under this plan. Out-of-pocket expenses are based only on treating the condition in the example. The patient received all care from innetwork providers. If the patient had received care from out-of-network providers, costs would have been higher. What does a Coverage Example show? For each treatment situation, the Coverage Example helps you see how deductibles, copayments, and co-insurance can add up. It also helps you see what expenses might be left up to you to pay because the service or treatment isn't covered or payment is limited. Does the Coverage Example predict my own care needs? No. Treatments shown are just examples. The care you would receive for this condition could be different based on your doctor's advice, your age, how serious your condition is, and many other factors. Does the Coverage Example predict my future expenses? No. Coverage Examples are not cost estimators. You can't use the examples to estimate costs for an actual condition. They are for comparative purposes only. Your own costs will be different depending on the care you receive, the prices your providers charge, and the reimbursement your health plan allows. Can I use Coverage Examples to compare plans? Yes. When you look at the Summary of Benefits and Coverage for other plans, you'll find the same Coverage Examples. When you compare plans, check the "Patient Pays" box in each example. The smaller that number, the more coverage the plan provides. Are there other costs I should consider when comparing plans? Yes. An important cost is the premium you pay. Generally, the lower your premium, the more you'll pay in out-ofpocket costs, such as co-payments, deductibles, and co-insurance. You should also consider contributions to accounts such as health savings accounts (HSAs), flexible spending arrangements (FSAs) or health reimbursement accounts (HRAs) that help you pay out-of-pocket expenses. Questions: Call or visit us at If you aren't clear about any of the underlined terms used in this form, see the Glossary. You can view the Glossary at or call to request a copy. Page 11 of 11

16 Your Summary of Benefits Prescription Drug Plan $10/$25/$45/20% PLEASE NOTE: This is only a summary of your benefits. Please refer to your Combined Evidence of Coverage and Disclosure Form ("EOC")/Certificate of Insurance ("Certificate") which explains your plan's Exclusions and Limitations as well as the full range of your covered services in detail. Getting a Prescription Filled at a Participating Pharmacy Finding a Participating Pharmacy Because our huge pharmacy network includes major drugstore chains plus a wide variety of independent pharmacies, it is easy for you to find a participating pharmacy. You can also find a participating pharmacy by calling Pharmacy Customer Service at or by going to our Web site at anthem.com/ca. To get a prescription filled, you need only take your prescription to a Using a Participating Pharmacy participating pharmacy and present your ID card. The amount you pay for a You can control the cost of your prescription drugs by using our network of covered prescription - your copay - will be determined by which formulary tier participating pharmacies. Participating pharmacies have agreed to charge you the drug falls into (a description of the drug tiers is listed below). not more than the prescription drug maximum allowed amount. A generic drug contains the same effective ingredients, meets the same Using a Non-Participating Pharmacy standards of purity as its brand-name counterpart and typically costs less. In If you choose to fill your prescription at a non-participating pharmacy, your many situations, you have a choice of filling your prescription with a generic costs may increase. You will likely need to pay for the entire amount of the medication or a brand-name medication. You may have to pay an additional prescription and then submit a prescription drug claim form for reimbursement charge that represents the cost difference between the brand-name to us. medication and the generic equivalent. Members that submit claims from non-participating pharmacies are Calendar year deductible (Cross application applies) $250/member; reimbursed based maximum on on of the three lesser separate of the deductibles/family billed charge or on a prescription The formulary is a list of recommended brand and generic medications. Drugs drug maximum allowed amount. The prescription drug maximum allowed on the formulary Deductible are for grouped non-anthem by tiers.' Blue A number Cross of PPO factors hospital are considered or residential treatment center $500/admission amount may be (waived considerably for emergency less than admission) you paid for your medication. You are when classifying drugs into tiers, including, but not limited to: the absolute responsible for paying any difference in cost between the prescription drug cost of Deductible the drug; the for cost non-anthem of drug relative Blue Cross to other PPO drugs hospital in the or same residential treatment center if utilization review not obtained $500/admission maximum allowed (waived amount for emergency and what you admission) paid for your medication. therapeutic class; the availability of over-the-counter alternatives; and other clinical Deductible and cost-effectiveness for emergency factors. room services $100/visit You may (waived obtain a if prescription admitted directly drug claim from form ER) by calling Pharmacy Customer Service at the toll-free number printed on your member ID card or by going to Annual Out-of-Pocket Maximums Tier 1 PPO Lowest Providers copayment & Other Drugs Health offering Care Providers the greatest value within a $3,500/insured our Web site at person/year; anthem.com/ca. $7,000/insured family/year therapeutic Non-PPO class. Providers Some of these are generic equivalents of brand name drugs. $10,000/insured person/year; $20,000/insured family/year Tier 2 Medium copayment Drugs on this tier are generally the more Home Delivery Program The following do not apply to out-of-pocket maximums: deductibles listed above; non-covered expense. After an insured person reaches the out-ofpocket brand-name maximum, drugs. the insured Other drugs person are no on longer this tier pays because percentage they are affordable If you take a prescription drug on a regular basis, you may want to take copays for the remainder of the year. However, insured person remains responsible "preferred" for deductibles within their listed therapeutic above; classes, for non-ppo based providers on clinical & other effectiveness advantage of our mail service program. To fill a prescription through the mail, health care providers, costs in excess of the covered expense; amounts related to a and value. transplant unrelated donor search. simply complete the Home Delivery form. You may obtain the form by calling Tier 3 Lifetime Highest copayment Maximum These are higher cost brand-name drugs. Some Customer Service, at the toll-free number listed on your ID card or by going to $5,000,000/insured person Tier 3 drugs may have generics or equivalents in Tier 1. In addition, some our Web site at anthem.com/ca. drugs on this tier may have been evaluated to be less cost-effective than Please note that not all medications are available through the Home Delivery Non-PPO: Per Insured Person Covered Services PPO: Per Insured Person Copay equivalent drugs on lower tiers. Program. Certain specialty pharmacy Copay drugs are not available through the home Tier 4 Tier Adult 4 drugs Preventive are those Services that have (including the higher mammograms, cost share than tier Pap 3 delivery program, see Specialty Pharmacy Program below. drugs. This smears, tier includes prostate non-preferred cancer screenings drugs that may & colorectal be generic, cancer single 30% Specialty Pharmacy Program 50% source brand screenings) name drugs, multi-source brand, or specialty drugs. (deductible Specialty waived) medications are usually dispensed (deductible as an waived) injectable drug, but may be Copies of Well our tiered Baby drug & Well-Child formulary Care list are for furnished Dependent to your Children providers. They available in other forms, such as a pill or inhalant. They are used to treat } Routine physical examinations (birth through age six) $30/exam (deductible waived) 50% are updated quarterly and are available online at click complex conditions. Prescriptions for specified specialty pharmacy drugs are (benefit limited to $20/exam) on Customer } Immunizations Care, Download (birth Forms through and then age choose six) Anthem Blue Cross Drug covered only when ordered through the specialty pharmacy program unless No copay 50% List (tiered). You or your provider may also contact our Pharmacy Customer you are given an exception from the specialty drug program (see (deductible waived) (benefit limited to $12/ Service at EOC/Certificate for details). The specialty immunization) pharmacy program will deliver your medication to you by mail or common carrier (you cannot pick up your You may Physical also sign up Exams online for to get Insured important Persons updates Ages by Seven . To & Older get updates medication). You may have to pay the full cost of a specialty pharmacy drug if } from us by , Routine follow physical these exams, steps: immunizations, - Log in to anthem.com/ca diagnostic X-ray - Choose & lab the for $30/exam (deductible waived) Not covered routine physical exam it is not obtained from the specialty pharmacy program. Specialty drugs that Profile Link in your Welcome section on the right side of the page - Enter your must be obtained through the specialty pharmacy program are limited to a address Physician in your Medical profile information Services - Check the box below your 30-day supply for each fill. } address to receive Office & information home visits from us. $30/visit (deductible waived) 2 50% (deductible waived) } Hospital & skilled nursing facility visits 30% 50% } Surgeon & surgical assistant; anesthesiologist or anesthetist 30% 50%

17 Covered Services (outpatient prescriptions only) Per Member Copay for Each Prescription or Refill Retail Participating Pharmacy Preventive immunizations administered by a retail pharmacy No copay Female oral contraceptives generic and single source brand No copay Tier 1 drugs (includes diabetic supplies) $10 Tier 2 drugs $25 Tier 3 drugs (includes compound drugs) $45 Tier 4 drugs 20% of prescription drug maximum allowed amount (maximum $150 copay per fill) Home Delivery Program Female oral contraceptives generic and single source brand No copay Tier 1 drugs (includes diabetic supplies) $10 Tier 2 drugs $50 Tier 3 drugs ƒ $90 Tier 4 drugs 20% of prescription drug maximum allowed amount (maximum $300 copay per fill) Specialty Pharmacy Program Requirements Certain specialty pharmacy drugs must be obtained through the specialty pharmacy program and are limited to a 30 day supply. Please contact customer service number on the back of your ID card to see if your drug is on the specialty pharmacy program or you can get a list of drugs required to be dispensed by our specialty pharmacy program at anthem.com/ca. From our home page: Click on Customer Care; Then select "I need to: Choose: Download Forms"; In the pharmacy library section, click on "Specialty Drug List." Applicable copay applies Out of Pocket Maximum Tier 4 Out of Pocket Maximum Tier 4 prescription drug coinsurance will accrue to a maximum of $3,500 per member per year. Once the member has satisfied the $3,500 maximum, no additional coinsurance will be required for the remainder of the year for Tier 4 prescription drugs. The pharmacy deductible does not accumulate towards this out of pocket maximum. Non-participating Pharmacies (compound drugs & certain specialty pharmacy drugs not covered) Member pays the above retail pharmacy copay plus 50% of the remaining prescription drug maximum allowed amount & costs in excess of the prescription drug maximum allowed amount Supply Limits Retail Pharmacy (participating and non-participating) 30-day supply; 60-day supply for federally classified Schedule II attention deficit disorder drugs that require a triplicate prescription form, but require a double copay; 6 tablets or units/30-day period for impotence and/or sexual dysfunction drugs (available only at retail pharmacies) Home Delivery 90-day supply Specialty Pharmacy 30-day supply

18 The Prescription Drug Benefit covers the following: Preventive flu, shingles and pneumonia vaccines administered by a participating retail pharmacy. Outpatient prescription drugs and medications which the law restricts to sale by prescription. Formulas prescribed by a physician for the treatment of phenylketonuria. Folic acid supplementation prescribed by a physician for women planning to become pregnant (folic acid supplement or a multivitamin) prescribed by a physician. Aspirin prescribed by a physician for the reduction of heart attack or stroke prescribed by a physician. Smoking cessation products and over-the-counter nicotine replacement products (limited to nicotine patches and gum) as prescribed by physician. Prescription drugs prescribed by a physician to eliminate or reduce dependency on, or addiction to, tobacco and tobacco products. Insulin. Syringes when dispensed for use with insulin and other self-injectable drugs or medications. All FDA-approved contraceptives for women, including oral contraceptives; contraceptive diaphragms and over-the-counter contraceptives prescribed by a doctor. Injectable drugs which are self-administered by the subcutaneous route (under the skin) by the patient or family member. Drugs that have Food and Drug Administration (FDA) labeling for self-administration. All compound prescription drugs that contain at least one covered prescription ingredient. Diabetic supplies (i.e., test strips and lancets). Prescription drugs for treatment of impotence and/or sexual dysfunction are limited to organic (non-psychological) causes. Inhaler spacers and peak flow meters for the treatment of pediatric asthma. These items are subject to the copay for tier 2 or tier 3 copay. Certain over-the-counter drugs approved by the Pharmacy and Therapeutics Process to be included in the prescription drug formulary. Prescription drug copays are separate from the medical copays of the medical plan and are not applied toward the Annual Out-of-Pocket Maximums under the Medical Plan. Classified specialty drugs must be obtained through our Specialty Pharmacy Program and are subject to the terms of the program. Preferred Generic Program. If a member requests a brand name drug when a generic drug version exists, the member pays the generic drug copay plus the difference in cost between the prescription drug maximum allowed amount for the generic drug and the brand name drug dispensed, but not more than 50% of our average cost of that type of prescription drug. The Preferred Generic Program does not apply when the physician has specified "dispense as written" (DAW) or when it has been determined that the brand name drug is medically necessary for the member. In such case, the applicable copay for the dispensed drug will apply. Supply limits for certain drugs may be different. Please refer to the EOC/Certificate for complete information. ƒ Compound drugs are not covered through home delivery; only covered through certain retail participating pharmacies.

19 Prescription Drug Exclusions & Limitations Immunizing agents, biological sera, blood, blood products or blood plasma. Hypodermic syringes &/or needles, except when dispensed for use with insulin & other self-injectable drugs or medications. Drugs & medications used to induce spontaneous & non-spontaneous abortions. Drugs & medications dispensed or administered in an outpatient setting, including outpatient hospital facilities and physicians' offices. Professional charges in connection with administering, injecting or dispensing drugs. Drugs & medications that may be obtained without a physician's written prescription, except insulin or niacin for cholesterol lowering and certain over-the-counter drugs approved by the Pharmacy and Therapeutics Process to be included in the prescription drug formulary. Drugs & medications dispensed by or while confined in a hospital, skilled nursing facility, rest home, sanatorium, convalescent hospital or similar facility. Durable medical equipment, devices, appliances & supplies, even if prescribed by a physician, except contraceptive diaphragms, as specified as covered in the EOC/Certificate. Services or supplies for which the member is not charged. Oxygen. Cosmetics & health or beauty aids. However, health aids that are medically necessary and meet the requirements as specified as covered in the EOC/Certificate. Drugs labeled "Caution, Limited by Federal Law to Investigational Use," or experimental drugs. Drugs or medications prescribed for experimental indications. Any expense for a drug or medication incurred in excess of the prescription drug maximum allowed amount. Drugs which have not been approved for general use by the Food and Drug Administration. This does not apply to drugs that are medically necessary for a covered condition. Drugs used primarily for cosmetic purposes (e.g., Retin-A for wrinkles). However, this will not apply to the use of this type of drug for medically necessary treatment of a medical condition other than one that is cosmetic. Drugs used primarily to treat infertility (including, but not limited to, Clomid, Pergonal and Metrodin), unless medically necessary for another condition. Anorexiants and drugs used for weight loss, except when used to treat morbid obesity (e.g., diet pills & appetite suppressants). Drugs obtained outside the U.S, unless they are furnished in connection with urgent care or an emergency. Allergy desensitization products or allergy serum. Infusion drugs, except drugs that are self-administered subcutaneously. Herbal supplements, nutritional and dietary supplements. Formulas and special foods for the treatment of phenylketonuria (PKU). Prescription drugs with a non-prescription (over-the-counter) chemical and dose equivalent except insulin. This does not apply if an over-the-counter equivalent was tried and was ineffective. Compound medications unless: a. There is at least one component in it that is a prescription drug; and b. It is obtained from a participating pharmacy. Member will have to pay the full cost of the compound medications if member obtains drug at a non-participating pharmacy. Specialty pharmacy drugs that must be obtained from the specialty pharmacy program, but which are obtained from a retail pharmacy are not covered by this plan. Member will have to pay the full cost of the specialty pharmacy drugs obtained from a retail pharmacy that member should have obtained from the specialty pharmacy program. Off label prescription drugs Third Party Liability Anthem Blue Cross is entitled to reimbursement of benefits paid if the member recovers damages from a legally liable third party. Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association. anthem.com/ca Anthem Blue Cross/Anthem Blue Cross Life and Health Insurance Company (P-NP) Effective Modified 09/2013 LR

20 Resource Advisor Knowing you have the support you need makes all the difference in the world When you feel pressure from everyday problems like work-related stress or family issues, Resource Advisor can help you get emotional, legal and financial support. No issue is too big or too small - and there s no extra cost to you. Call us support is one phone call away 24/7 You and your family can talk to a Resource Advisor counselor by phone who can: Give you advice and arrange for up to three visits with a counselor, if you need it. Put you in touch with a financial advisor if you have money problems. Connect you with a lawyer if you need legal help. You can meet by phone or in person. Let us help if your identity is stolen If your wallet or purse is lost or your identity stolen, we ll assign a Fraud Resolution Specialist to help get your identity back and restore your good credit. Services include: Placing fraud alerts on credit reports and with creditors. Closing bank and credit card accounts where your identity is an issue. Arranging a phone meeting with a financial counselor. Setting up a meeting with a lawyer on issues around the identity theft (each visit must be for a separate issue). Go online for help any time... and a lot more When you visit ResourceAdvisorCA.Anthem.com, you ll find: Tips on handling difficult life events and a depression screening tool. Parenting information. There s even a child and elder care provider finder. Financial tools to help you plan for major purchases or life events. You and your family members can register for identity monitoring at no cost. State-specific online wills and a legal library. Give added support to beneficiaries when they need it most Providing your loved ones with a little extra comfort and emotional support after you re gone is a lasting gift. Resource Advisor gives your beneficiaries: Three meetings with a mental health professional. Meetings with a legal and/or financial professional. Copies of The Healing Book: Facing the Death and Celebrating the Life of Someone You Love. This is a great resource book to talk to children about loss. Beneficiary Companion* services to help your family with estate details like closing bank accounts, credit cards and utilities. ResourceAdvisorCA.Anthem.com Note: If you retire, you can only use Resource Advisor until your retirement starts. * Beneficiary Companion services are provided by Europ Assistance USA, an independent company providing these services on behalf of Anthem Life. Keep Resource Advisor close at hand. Just cut out and carry the wallet card. Get support, advice and resources 24/7. Call or visit ResourceAdvisorCA.Anthem.com. Then log in with the program name: ResourceAdvisor. The expected benefit ratio for the disability policies is 60% for groups of less than 50 lives, and 65% for groups of 50 or more lives. This ratio is the portion of future premiums which the company expects to return as benefits, when averaged over all people with this policy. This is just a brief outline of what we have to offer and does not include all terms of coverage. Life products underwritten by Anthem Blue Cross Life and Health Insurance Company; Disability products underwritten by Anthem Life Insurance Company. Independent licensees of the Blue Cross Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association CAMESLBC 5/12 Cut along the dotted line Life products underwritten by Anthem Blue Cross Life and Health Insurance Company; Disability products underwritten b Anthem Life Insurance Company. Independent licensees of the Blue Cross Association. ANTHEM is a registered tradem of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Associatio