Benefit Summary Guide Health plan information for individuals & families

Transcription

1 Effective: January 1, 2015 Summary Guide Health plan information for individuals & families American Indian Alaska Native

2 Healthcare coverage that fits your needs We offer a range of American Indian - Alaska Native* health plans to choose from, with easy access to care from our quality provider networks, as well as American Indian and Alaska Native providers. When you choose a Blue Shield plan, you ll also have access to a variety of health and wellness resources and programs to help you maintain your health. Plus, Blue Shield offers dental products to complement your coverage. This guide provides a summary of plan benefits and is not a contract. The actual, complete terms and conditions of a plan s benefits and coverage, limitations, and exclusions are located in the Evidence of Coverage and Health Service Agreement (EOC) or Policy. A copy of the EOC or Policy is available upon request prior to enrollment. We ll provide your EOC/Policy to you if your application for coverage is approved. Please note: The Important Legal Information booklet, explaining general plan exclusions and limitations, is a companion to this guide. Please read both documents together. For questions about plan information or to obtain a copy of the Important Legal Information booklet, contact your broker, call us at (888) , or visit us online at blueshieldca.com. * Some plans have specific eligibility criteria. American Indian - Alaska Native plans are only available to eligible American Indians and Alaska Natives. American Indian and Alaska Native means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as American Indian and Alaska Native is determined by Covered California. ii choosing your health plan

3 In this guide, you ll find detailed benefit information for Blue Shield health plans available for purchase through Covered California ( Covered California is the state of California s health insurance marketplace, where you can compare and purchase health plans, and determine if you qualify for tax credits or cost-sharing subsidies from government assistance programs to lower your monthly health coverage costs. Blue Shield medical plans available through Covered California Platinum 90 PPO AI-AN Platinum 90 EPO AI-AN Gold 80 PPO AI-AN Gold 80 EPO AI-AN Silver 70 PPO AI-AN Silver 70 EPO AI-AN Bronze 60 PPO AI-AN Bronze 60 EPO AI-AN Bronze 60 HSA PPO AI-AN Bronze 60 HSA EPO AI-AN Cost Share PPO AI-AN Cost Share EPO AI-AN * Individual and Family Plans rates and benefits are pending regulatory approval. choosing your health plan iii

4 table of contents Health plans PPO/EPO health plans Plans at a glance... 1 Platinum 90 PPO/EPO plans benefit summaries... 3 Gold 80 PPO/EPO plans benefit summaries Silver PPO/EPO plans benefit summaries Bronze 60 PPO/EPO plans benefit summaries Cost Share PPO/EPO plans benefit summaries HSA-eligible, high-deductible PPO/EPO health plans Plans at a glance Bronze 60 HSA PPO/EPO plans benefit summaries iv choosing your health plan

5 Preferred Provider Organization (PPO) and Exclusive Provider Organization (EPO) health plans PPO/EPO plans at a glance Blue Shield PPO/EPO plans vary by member out-of-pocket costs, but all offer members the flexibility and simplicity of having direct access to the physicians and specialists in Blue Shield s provider networks without the need for a referral. Additional highlights include: Comprehensive benefits Predictable copayments and out-of-pocket Preventive care services without a copayment before meeting any annual deductible Access to quality provider networks in California Blue Shield PPO plans are available in the following counties Contra Costa El Dorado Fresno Imperial Inyo Kern Kings Los Angeles Madera Mariposa Merced Mono Orange County Placer Riverside Sacramento San Bernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Stanislaus Tulare Ventura Yolo Blue Shield EPO plans are available in the following counties Alameda Amador Butte Calaveras Colusa Del Norte Glenn Humboldt Lake Lassen Marin Mendocino Modoc Napa Nevada Plumas San Benito Santa Cruz Shasta Sierra Siskiyou Solano Sonoma Tehama Trinity Tuolumne Blue Shield EPO plans are not available in the following ZIP codes for the following counties: Alameda: 94505, 94514, 94536, 94538, 94539, 94555, 94560, 94583, 94586, 94587, 95035, 95304, 95377, Amador: 95629, 95644, 95646, 95666, 95669, Butte: 95901, 95914, 95925, 95930, 95941, 95942, Calaveras: 95223, 95224, 95228, 95229, 95230, 95232, 95233, 95236, 95245, 95247, 95248, 95251, 95254, 95255, Colusa: 95645, 95939, 95955, 95957, 95979, Del Norte: 00049, 95543, Glenn: 00047, 95920, 95939, 95951, Humboldt: 00050, 00054, 95514, 95526, 95528, 95546, 95549, 95550, 95552, 95554, 95555, 95556, 95558, 95563, 95565, 95569, 95570, 95571, 95573, 95587, Lake: 00048, 95423, Lassen: 00012, 00019, 96006, 96009, 96056, 96068, 96109, 96113, 96114, 96117, 96119, 96121, 96123, 96128, 96132, Marin: 94929, 94937, 94940, Mendocino: 00022, 95410, 95415, 95417, 95425, 95427, 95428, 95429, 95432, 95445, 95449, 95454, 95459, 95463, 95466, 95468, 95469, 95488, 95494, 95585, 95587, Modoc: 96006, 96015, 96054, 96056, 96108, 96110, 96112, 96116, Nevada: 95602, 95728, 95959, 95960, 95977, 95986, Plumas: 00028, 00031, 95915, 95947, 95980, 95981, 95983, San Benito: 93210, 93925, 93930, 95004, 95020, Santa Cruz: 94060, 95006, 95017, Shasta: 96008, 96011, 96013, 96017, 96022, 96033, 96040, 96047, 96051, 96056, 96059, 96062, 96065, 96069, 96070, 96071, 96076, 96084, 96088, Sierra: 00033, 00065, 95960, 96118, 96124, Siskiyou: 00034, 00035, 95568, 96014, 96023, 96027, 96031, 96032, 96034, 96037, 96039, 96044, 96050, 96057, 96058, 96064, 96085, 96086, 96091, 96094, Solano: 94512, 94533, 94535, 94571, 94585, 95616, 95618, 95620, 95625, 95687, 95688, 95690, 95694, Sonoma: 95412, 95421, 95425, 95450, 95480, 95486, Tehama: 00037, 00038, 95963, 96021, 96022, 96029, 96059, 96061, 96074, 96075, 96076, Trinity: 00039, 00055, 95526, 95527, 95543, 95552, 95563, 95595, 96041, 96046, 96076, Tuolumne: 00040, 95230, 95305, 95311, 95321, 95329, 95335, 95364, choosing your health plan 1

6 Provider network The PPO/EPO health plans offered by Blue Shield of California use the Exclusive PPO and EPO Networks. These networks consist of participating doctors and hospitals. Visit blueshieldca.com/fap to see if your provider is in one of our networks. Access to care and limitations Plan features and copayments vary by plan. Members who receive care from a provider in their plan s provider network (participating provider) are responsible for meeting the plan s calendar-year deductible (if applicable) and copayments or coinsurance up to the calendar-year out-of-pocket for covered services. Members who receive care from an American Indian or Alaska Native provider are not required to meet a deductible, and will pay out of pocket when accessing covered benefits. A PPO plan provides access to an Exclusive Network of participating doctors, specialists, and hospitals. Members have the freedom to see any doctor in our Exclusive PPO Network, or any American Indian or Alaska Native provider, without a referral. Members have the option to receive care from non-participating providers, but are then responsible for meeting their plan s non-participating provider calendar-year deductible (if applicable), the copayment or coinsurance up to the non-participating provider calendaryear out-of-pocket, and all charges that exceed Blue Shield s allowable amount. An EPO plan provides access to a network of participating doctors, specialists, and hospitals. Members have the freedom to see any doctor in our EPO Network, or any American Indian or Alaska Native provider, without a referral. However, there s no coverage for services received from non-participating providers, except urgent and emergency care services. Members who receive non-urgent or non-emergency care from non-participating providers are responsible for all billed charges. The EPO Network and the Exclusive PPO Network fewer providers than Blue Shield s Full PPO Network. Certain healthcare services may not be available in your area. You may be required to travel in excess of 30 minutes to access these services. 2 choosing your health plan

7 Platinum 90 PPO AI-AN This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This PPO plan uses the Exclusive PPO provider network. Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum 3 $4,000 per individual / $8,000 per family $7,000 per individual / $14,000 per family Calendar Year Brand Drug Deductible Lifetime Maximum None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians $20 50% Specialist physician office visits $40 50% Outpatient diagnostic X-ray and imaging $40 50% (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) $20 50% OUTPATIENT SERVICES Outpatient surgery in a hospital 10% 50% 4 Outpatient surgery performed at an ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies The allowed 10% 50% 5 The allowed $300 per day. for 50% of this $300 per excess of $300 10% 50% 4 The allowed choosing your health plan 3

8 Outpatient diagnostic X-ray and imaging performed in a hospital Outpatient diagnostic laboratory and pathology performed in a hospital CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required) $40 50% 4 The allowed $20 50% 4 The allowed 10% 50% 6 The allowed HOSPITALIZATION SERVICES Inpatient physician services 10% 50% Inpatient non-emergency facility services (semi-private room and board, services and supplies, including subacute care) 10% 50% 4 The allowed Bariatric surgery (prior authorization is required; medically 10% necessary surgery for weight loss is for morbid obesity only) 7 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission $150 $150 Emergency room services resulting in admission (when the member is admitted directly from the ER) 10% 10% Emergency room physician services 10% 10% Urgent care $40 50% AMBULANCE SERVICES Emergency or authorized transport (ground or air) $150 $150 PRESCRIPTION DRUG COVERAGE 8,9,10 Pharmacy 1 Pharmacy Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 9 Generic drugs $5 per prescription Preferred brand drugs $15 per prescription Non-preferred brand drugs $25 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 9 Generic drugs $15 per prescription Preferred brand drugs $45 per prescription Non-preferred brand drugs $75 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) 10% Oral Anti-cancer Medications 10% up to a of $200 per prescription 4 choosing your health plan

9 PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) 10% 50% 10% 50% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 10% 50% MENTAL HEALTH SERVICES 11 Inpatient hospital services (prior authorization required) 10% 50% 4 Outpatient mental health services (some services may require prior authorization and facility charges) The allowed $20 50% SUBSTANCE ABUSE SERVICES 11 Inpatient hospital services (prior authorization required) 10% 50% 4 Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) The allowed $20 50% 10% (unless prior authorized) OTHER Pregnancy and Maternity Care s Prenatal physician office visits 50% Postnatal physician office visits $20 50% Inpatient hospital services for normal delivery and cesarean section 10% 50% 4 The allowed Abortion services 12 10% 50% Family Planning s Injectable and implantable contraceptives Counseling and consulting Tubal ligation Vasectomy 10% Infertility services Rehabilitation and Habilitation s Office location $20 50% Outpatient department of a hospital $20 50% 4 Chiropractic s The allowed choosing your health plan 5

10 Chiropractic services Acupuncture s Acupuncture services $20 50% Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Child Dental Diagnostic and Preventive Oral exam No charge No charge 20% Preventive - cleaning No charge No charge 20% Preventive - X-ray No charge No charge 20% Sealants per tooth No charge No charge 20% Topical fluoride application No charge No charge 20% Caries risk management No charge No charge 20% Space maintainers - fixed No charge No charge 20% Child Dental Basic Services Amalgam fill - 1 surface No charge 20% 30% Child Dental Major Services 2 Root canal - molar No charge 50% 50% Gingivectomy per quad No charge 50% 50% Extraction - single tooth exposed root or No charge 50% 50% Extraction - complete bony No charge 50% 50% Porcelain with metal crown No charge 50% 50% Child Orthodontics 2 Medically necessary orthodontics No charge 50% 50% Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 13 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exam (92002/92004) - Established patient exam (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. Covered up to a allowance of $30 Covered up to a allowance of $30 Covered up to a allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating (standard only) Anti-reflective coating (standard only) $35 High-index lenses $30 Photochromic lenses (glass or plastic) $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame (one frame per calendar year) Collection frame Covered up to a 6 choosing your health plan

11 Non-collection frame 14 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 15 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Covered up to a allowance of $150 Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary to 6 months) to 3 months) allowance $40 Covered up to a allowance of $75 Covered up to a allowance of $75 Covered up to a allowance of $75 Covered up to a allowance of $75 Covered up to a allowance of $225 for medically necessary contact lenses Other Pediatric Vision s Supplemental low-vision testing and equipment 16 35% Diabetes management referral Please Note: s are subject to modification for subsequently enacted state or federal legislation. Pediatric Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. choosing your health plan 7

12 Endnotes for Platinum 90 PPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 Members enrolled in this plan can access benefits from any provider, including a Blue Shield participating provider, a nonparticipating provider, or a provider for s; however, there is no member cost-sharing for services received from a provider or pharmacy for s. s from a provider or pharmacy for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 The member is responsible for a copayment or coinsurance from participating providers. providers accept Blue Shield s allowable amounts as full payment for covered services. Non-participating providers can charge more than these amounts which the member is responsible for in addition to the applicable copayment or coinsurance when accessing these providers, which amount can be substantial. Charges in excess of the allowable amount do not count toward the calendar year out-of-pocket. 3 Copayments or coinsurance for covered services apply toward the calendar year out-of-pocket, except copayments or coinsurance for the following: (a) charges in excess of specified benefit s; (b) covered travel expenses for bariatric surgery; and (c) dialysis center services from a non-participating provider. Copayments, coinsurance, and charges for services not accruing to the calendar year out-of-pocket continue to be the member s responsibility after the calendar year out-of-pocket is reached. 4 The allowable amount for non-emergency services and supplies received from a non-participating hospital or facility is limited to for the coinsurance and all charges that exceed 5 The allowable amount for non-emergency services and supplies received from an ambulatory surgery center is limited to $300 per day. for the coinsurance and all charges that exceed $300 per day. ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 6 The allowable amount for non-emergency services and supplies received from a non-participating radiology center is limited to $300 per day. for all charges that exceed $300 per day. The allowable amount for non-emergency services and supplies received from a non-participating hospital is limited to for all charges that exceed 7 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage and Summary of s for details. 8 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 Medicare Part D premium. 9 Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment; however, if a brand contraceptive drug is requested when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year out-of-pocket responsibility. 10 If a member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost that the member must pay does not accrue to any calendar year out-of-pocket responsibility. Refer to the Evidence of Coverage and Summary of s for details. 11 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for acute medical detoxification, through a separate network of MHSA participating providers. Inpatient acute medical detoxification is a medical benefit provided by Blue Shield participating or non-participating (not MHSA) providers. 12 Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 13 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 14 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 15 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 16 A report from the provider and prior authorization from the Vision Plan Administrator is required. This plan is pending regulatory approval. 8 choosing your health plan

13 Platinum 90 EPO AI-AN This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This EPO plan uses the EPO provider network. This exclusive provider organization (EPO) plan utilizes a network of Providers. Except for Emergency Services, Urgent Services, or when prior authorized by Blue Shield, all services must be obtained from Providers to be covered. Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum 3 (Services received from providers are not subject to a calendar year out-of-pocket. Services received from participating providers are subject to a calendar year out-of-pocket.) $4,000 per individual / $8,000 per family Calendar Year Brand Drug Deductible Lifetime Maximum None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians $20 Specialist physician office visits $40 Outpatient diagnostic X-ray and imaging $40 (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) $20 OUTPATIENT SERVICES Outpatient surgery in a hospital 10% Outpatient surgery performed at an ambulatory 10% surgery center 4 Outpatient services for treatment of illness or injury 10% and necessary supplies Outpatient diagnostic X-ray and imaging performed in a hospital Outpatient diagnostic laboratory and pathology performed in a hospital CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required) HOSPITALIZATION SERVICES $40 $20 10% Inpatient physician services 10% Inpatient non-emergency facility services (semi-private room and board, services and supplies, including subacute care) 10% choosing your health plan 9

14 Bariatric surgery (prior authorization is required; medically 10% necessary surgery for weight loss is for morbid obesity only) 5 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission $150 $150 Emergency room services resulting in admission (when the member is admitted directly from the ER) 10% 10% Emergency room physician services 10% 10% Urgent care $40 $40 AMBULANCE SERVICES Emergency or authorized transport (ground or air) $150 $150 PRESCRIPTION DRUG COVERAGE 6,7,8 Pharmacy Pharmacy Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 7 Generic drugs $5 per prescription Preferred brand drugs $15 per prescription Non-preferred brand drugs $25 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 7 Generic drugs $15 per prescription Preferred brand drugs $45 per prescription Non-preferred brand drugs $75 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) 10% Oral Anti-cancer Medications 10% up to a of $200 per prescription PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) 10% 10% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 10% MENTAL HEALTH SERVICES 9 Inpatient hospital services (prior authorization required) 10% Outpatient mental health services (some services may require prior authorization and facility charges) SUBSTANCE ABUSE SERVICES 9 $20 Inpatient hospital services (prior authorization required) 10% Outpatient substance abuse services $20 (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) 10% OTHER Pregnancy and Maternity Care s Prenatal physician office visits Postnatal physician office visits $20 Inpatient hospital services for normal delivery and 10% cesarean section Abortion services 10 10% Family Planning s Injectable and implantable contraceptives Counseling and consulting 10 choosing your health plan

15 Tubal ligation Vasectomy 10% Infertility services Rehabilitation and Habilitation s Office location $20 Outpatient department of a hospital $20 Chiropractic s Chiropractic services Acupuncture s Acupuncture services $20 Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Child Dental Diagnostic and Preventive Oral exam No charge No charge Preventive - cleaning No charge No charge Preventive - X-ray No charge No charge Sealants per tooth No charge No charge Topical fluoride application No charge No charge Caries risk management No charge No charge Space maintainers - fixed No charge No charge Child Dental Basic Services Amalgam fill - 1 surface No charge 20% Child Dental Major Services 2 Root canal - molar No charge 50% Gingivectomy per quad No charge 50% Extraction - single tooth exposed root or No charge 50% Extraction - complete bony No charge 50% Porcelain with metal crown No charge 50% Child Orthodontics 2 Medically necessary orthodontics No charge 50% Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 11 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exam (92002/92004) - Established patient exam (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. Optional Lenses and Treatments UV coating (standard only) Anti-reflective coating (standard only) $35 High-index lenses $30 choosing your health plan 11

16 Photochromic lenses (glass or plastic) $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame (one frame per calendar year) Collection frame Non-collection frame 12 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 13 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary Covered up to a allowance of $150 to 6 months) to 3 months) Other Pediatric Vision s Supplemental low-vision testing and equipment 14 35% Diabetes management referral Please Note: s are subject to modification for subsequently enacted state or federal legislation. Pediatric Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. 12 choosing your health plan

17 Endnotes for Platinum 90 EPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 There is no member cost-sharing for services received from a provider or pharmacy for s. s from a provider or pharmacy for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 The member is responsible for a copayment or coinsurance from participating providers. providers accept Blue Shield s allowable amounts as full payment for covered services. There is no non-emergency coverage for non-participating providers under the plan. for the full amount charged by non-participating providers. 3 Copayments or coinsurance for covered services apply toward the calendar year out-of-pocket, except copayments or coinsurance for the following: (a) charges in excess of specified benefit s; and (b) covered travel expenses for bariatric surgery. Copayments, coinsurance, and charges for services not accruing to the calendar year out-of-pocket continue to be the member s responsibility after the calendar year out-of-pocket is reached. 4 ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 5 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage and Summary of s for details. 6 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 Medicare Part D premium. 7 Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment; however, if a brand contraceptive drug is requested when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year out-of-pocket responsibility. Select contraceptives may need prior authorization to be covered without a copayment. 8 If a member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost that the member must pay does not accrue to any calendar year out-of-pocket responsibility. Refer to the Evidence of Coverage and Summary of s for details. 9 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for acute medical detoxification, through a separate network of MHSA participating providers. Inpatient acute medical detoxification is a medical benefit provided by Blue Shield participating providers. 10 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 11 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 12 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 13 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 14 A report from the provider and prior authorization from the Vision Plan Administrator is required. This plan is pending regulatory approval. choosing your health plan 13

18 Gold 80 PPO AI-AN This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This PPO plan uses the Exclusive PPO provider network. Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum 3 $6,250 per (Services received from providers are not subject to a individual / $12,500 calendar year out-of-pocket. Services received from all other per family providers are subject to a calendar year out-of-pocket. Copayments for participating providers apply to both participating and nonparticipating provider calendar year out-of-pocket amounts.) $9,250 per individual / $18,500 per family Calendar Year Brand Drug Deductible Lifetime Maximum None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians $30 50% Specialist physician office visits $50 50% Outpatient diagnostic X-ray and imaging $50 50% (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) $30 50% OUTPATIENT SERVICES Outpatient surgery in a hospital 20% 50% 4 Outpatient surgery performed at an ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies The allowed 20% 50% 5 The allowed $300 per day. for 50% of this $300 per excess of $300 20% 50% 4 The allowed 14 choosing your health plan

19 Outpatient diagnostic X-ray and imaging performed in a hospital Outpatient diagnostic laboratory and pathology performed in a hospital CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required) $50 50% 4 The allowed $30 50% 4 The allowed 20% 50% 6 The allowed HOSPITALIZATION SERVICES Inpatient physician services 20% 50% Inpatient non-emergency facility services (semi-private room and board, services and supplies, including subacute care) 20% 50% 4 The allowed Bariatric surgery (prior authorization is required; medically 20% necessary surgery for weight loss is for morbid obesity only) 7 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission $250 $250 Emergency room services resulting in admission 20% 20% (when the member is admitted directly from the ER) Emergency room physician services 20% 20% Urgent care $60 50% AMBULANCE SERVICES Emergency or authorized transport (ground or air) $250 $250 PRESCRIPTION DRUG COVERAGE 8,9,10 Pharmacy 1 Pharmacy Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 9 Generic drugs $15 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $70 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 9 Generic drugs $45 per prescription Preferred brand drugs $150 per prescription Non-preferred brand drugs $210 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. 20% choosing your health plan 15

20 Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) Oral Anti-cancer Medications 20% up to a of $200 per prescription PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) 20% 50% 20% 50% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 20% 50% MENTAL HEALTH SERVICES 11 Inpatient hospital services (prior authorization required) 20% 50% 4 Outpatient mental health services (some services may require prior authorization and facility charges) The allowed $30 50% SUBSTANCE ABUSE SERVICES 11 Inpatient hospital services d (prior authorization required) 20% 50% 4 Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) The allowed $30 50% 20% (unless prior authorized) OTHER Pregnancy and Maternity Care s Prenatal physician office visits 50% Postnatal physician office visits $30 50% Inpatient hospital services for normal delivery and cesarean section 20% 50% 4 The allowed Abortion Services 12 20% 50% Family Planning s Injectable and implantable contraceptives Counseling and consulting Tubal ligation Vasectomy 20% Infertility services Rehabilitation and Habilitation s Office location $30 50% 16 choosing your health plan

21 Outpatient department of a hospital $30 50% 4 The allowed Chiropractic s Chiropractic services Acupuncture s Acupuncture services $30 50% Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Child Dental Diagnostic and Preventive Oral exam No charge No charge 20% Preventive - cleaning No charge No charge 20% Preventive - X-ray No charge No charge 20% Sealants per tooth No charge No charge 20% Topical fluoride application No charge No charge 20% Caries risk management No charge No charge 20% Space maintainers - fixed No charge No charge 20% Child Dental Basic Services Amalgam fill - 1 surface No charge 20% 30% Child Dental Major Services 2 Root canal - molar No charge 50% 50% Gingivectomy per quad No charge 50% 50% Extraction - single tooth exposed root or No charge 50% 50% Extraction - complete bony No charge 50% 50% Porcelain with metal crown No charge 50% 50% Child Orthodontics 2 Medically necessary orthodontics No charge 50% 50% Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 13 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exam (92002/92004) - Established patient exam (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. Covered up to a allowance of $30 Covered up to a allowance of $30 Covered up to a allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating (standard only) choosing your health plan 17

22 Anti-reflective coating (standard only) $35 High-index lenses $30 Photochromic lenses (glass or plastic) $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame (one frame per calendar year) Collection frame Non-collection frame 14 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 15 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Covered up to a allowance of $150 to 6 months) Covered up to a allowance $40 Covered up to a allowance of $75 Covered up to a allowance of $75 Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Elective non-standard soft (V2521, V2512, V2523) to 3 months) to 3 months) Covered up to a allowance of $75 Covered up to a allowance of $75 Medically necessary Covered up to a allowance of $225 for medically necessary contact lenses Other Pediatric Vision s Supplemental low-vision testing and equipment 16 35% Diabetes management referral Please Note: s are subject to modification for subsequently enacted state or federal legislation. Pediatric Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). 18 choosing your health plan

23 Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. Endnotes for Gold 80 PPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 Members enrolled in this plan can access benefits from any provider, including a Blue Shield participating provider, a nonparticipating provider, or a provider for s; however, there is no member cost-sharing for services received from a provider or pharmacy for s. s from a provider or pharmacy for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 The member is responsible for a copayment or coinsurance from participating providers. providers accept Blue Shield s allowable amounts as full payment for covered services. Non-participating providers can charge more than these amounts which the member is responsible for in addition to the applicable copayment or coinsurance when accessing these providers, which amount can be substantial. Charges in excess of the allowable amount do not count toward the calendar year out-of-pocket. 3 Copayments or coinsurance for covered services apply toward the calendar year out-of-pocket, except copayments or coinsurance for the following: (a) charges in excess of specified benefit s; (b) covered travel expenses for bariatric surgery; and (c) dialysis services from a non-participating provider. Copayments, coinsurance, and charges for services not accruing to the calendar year out-of-pocket continue to be the member s responsibility after the calendar year out-of-pocket is reached. 4 The allowable amount for non-emergency services and supplies received from a non-participating hospital or facility is limited to for the coinsurance and all charges that exceed 5 The allowable amount for non-emergency services and supplies received from an ambulatory surgery center is limited to $300 per day. for the coinsurance and all charges that exceed $300 per day. ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 6 The allowable amount for non-emergency services and supplies received from a non-participating radiology center is limited to $300 per day. for all charges that exceed $300 per day. The allowable amount for non-emergency services and supplies received from a non-participating hospital is limited to for all charges that exceed 7 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage and Summary of s for details. 8 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 Medicare Part D premium. 9 Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment; however, if a brand contraceptive drug is requested when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year out-of-pocket responsibility. 10 If a member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost that the member must pay does not accrue to any calendar year out-of-pocket responsibility. Refer to the Evidence of Coverage and Summary of s for details. 11 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for acute medical detoxification, through a separate network of MHSA participating providers. Inpatient acute medical detoxification is a medical benefit provided by Blue Shield participating or non-participating (not MHSA) providers. 12 Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 13 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 14 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. choosing your health plan 19

24 15 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 16 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required. This plan is pending regulatory approval. 20 choosing your health plan

25 Gold 80 EPO AI-AN This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This EPO plan uses the EPO provider network. This exclusive provider organization (EPO) plan utilizes a network of Providers. Except for Emergency Services, Urgent Services, or when prior authorized by Blue Shield, all services must be obtained from Providers to be covered. Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum 3 $6,250 per (Services received from providers are not subject to a individual / $12,500 calendar year out-of-pocket. Services received from participating per family providers are subject to a calendar year out-of-pocket.) Calendar Year Brand Drug Deductible Lifetime Maximum None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians $30 Specialist physician office visits $50 Outpatient diagnostic X-ray and imaging $50 (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) $30 OUTPATIENT SERVICES Outpatient surgery in a hospital 20% Outpatient surgery performed at an ambulatory 20% surgery center 4 Outpatient services for treatment of illness or injury 20% and necessary supplies Outpatient diagnostic X-ray and imaging performed in a hospital Outpatient diagnostic laboratory and pathology performed in a hospital CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required) HOSPITALIZATION SERVICES $50 $30 20% Inpatient physician services 20% Inpatient non-emergency facility services 20% (semi-private room and board, services and supplies, including subacute care) Bariatric surgery (prior authorization is required; medically 20% necessary surgery for weight loss is for morbid obesity only) 5 EMERGENCY HEALTH COVERAGE choosing your health plan 21

26 Emergency room services not resulting in admission $250 $250 Emergency room services resulting in admission 20% 20% (when the member is admitted directly from the ER) Emergency room physician services 20% 20% Urgent care $60 $60 AMBULANCE SERVICES Emergency or authorized transport (ground or air) $250 $250 PRESCRIPTION DRUG COVERAGE 6,7,8 Pharmacy Pharmacy Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 7 Generic drugs $15 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $70 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 7 Generic drugs $45 per prescription Preferred brand drugs $150 per prescription Non-preferred brand drugs $210 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) 20% Oral Anti-cancer Medications 20% up to a of $200 per prescription PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) 20% 20% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 20% MENTAL HEALTH SERVICES 9 Inpatient hospital services (prior authorization required) 20% Outpatient mental health services (some services may require prior authorization and facility charges) SUBSTANCE ABUSE SERVICES 9 $30 Inpatient hospital services (prior authorization required) 20% Outpatient substance abuse services $30 (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) 20% OTHER Pregnancy and Maternity Care s Prenatal physician office visits Postnatal physician office visits $30 Inpatient hospital services for normal delivery and 20% cesarean section Abortion services 10 20% Family Planning s Injectable and implantable contraceptives Counseling and consulting Tubal ligation 22 choosing your health plan

27 Vasectomy 20% Infertility services Rehabilitation and Habilitation s Office location $30 Outpatient department of a hospital $30 Chiropractic s Chiropractic services Acupuncture s Acupuncture services $30 Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Child Dental Diagnostic and Preventive Oral exam No charge No charge Preventive - cleaning No charge No charge Preventive - X-ray No charge No charge Sealants per tooth No charge No charge Topical fluoride application No charge No charge Caries risk management No charge No charge Space maintainers - fixed No charge No charge Child Dental Basic Services Amalgam fill - 1 surface No charge 20% Child Dental Major Services 2 Root canal - molar No charge 50% Gingivectomy per quad No charge 50% Extraction - single tooth exposed root or No charge 50% Extraction - complete bony No charge 50% Porcelain with metal crown No charge 50% Child Orthodontics 2 Medically necessary orthodontics No charge 50% Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 11 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exam (92002/92004) - Established patient exam (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. Optional Lenses and Treatments UV coating (standard only) Anti-reflective coating (standard only) $35 High-index lenses $30 Photochromic lenses (glass or plastic) $25 choosing your health plan 23

28 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame (one frame per calendar year) Collection frame Non-collection frame 12 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 13 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary Covered up to a allowance of $150 to 6 months) to 3 months) Other Pediatric Vision s Supplemental low-vision testing and equipment 14 35% Diabetes management referral Please Note: s are subject to modification for subsequently enacted state or federal legislation. Pediatric Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. 24 choosing your health plan

29 Endnotes for Gold 80 EPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 There is no member cost-sharing for services received from a provider or pharmacy for s. s from a provider or pharmacy for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 The member is responsible for a copayment or coinsurance from participating providers. providers accept Blue Shield s allowable amounts as full payment for covered services. There is no non-emergency coverage for non-participating providers under the plan. for the full amount charged by non-participating providers. 3 Copayments or coinsurance for covered services apply toward the calendar year out-of-pocket, except copayments or coinsurance for the following: (a) charges in excess of specified benefit s; and (b) covered travel expenses for bariatric surgery. Copayments, coinsurance, and charges for services not accruing to the calendar year out-of-pocket continue to be the member s responsibility after the calendar year out-of-pocket is reached. 4 ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 5 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage and Summary of s for details. 6 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 Medicare Part D premium. 7 Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment; however, if a brand contraceptive drug is requested when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year out-of-pocket responsibility. Select contraceptives may need prior authorization to be covered without a copayment. 8 If a member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost that the member must pay does not accrue to any calendar year out-of-pocket responsibility. Refer to the Evidence of Coverage and Summary of s for details. 9 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for acute medical detoxification, through a separate network of MHSA participating providers. Inpatient acute medical detoxification is a medical benefit provided by Blue Shield participating providers. 10 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 11 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 12 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 13 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 14 A report from the provider and prior authorization from the Vision Plan Administrator is required. This plan is pending regulatory approval. choosing your health plan 25

30 Silver 70 PPO AI-AN This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This PPO plan uses the Exclusive PPO provider network. Calendar Year Medical Deductible 3 (Services received from providers are not subject to a deductible. Services received from all other providers are subject to a deductible. For family coverage, an individual is responsible for satisfying their own individual deductible and that amount accumulates to the family deductible.) Calendar Year Out-of-Pocket Maximum 4 (Services received from providers are not subject to a calendar year out-of-pocket. Services received from all other providers are subject to a calendar year out-of-pocket. The calendar year out-of-pocket includes the calendar year medical deductible. Copayments for participating providers apply to both participating and non-participating provider calendar year out-of-pocket amounts.) Calendar Year Brand Drug Deductible (Brand drugs received from pharmacies are not subject to the calendar year brand drug deductible. Brand drugs received from a Blue Shield participating pharmacy are subject to the calendar year brand drug deductible. For family coverage, an individual is responsible for satisfying their own individual deductible and that amount accumulates to the family deductible. The calendar year brand drug deductible is separate from the calendar year medical deductible and accrues to the calendar year out-ofpocket.) Lifetime Maximum $2,000 per individual / $4,000 per family (all providers combined) $6,250 per individual / $12,500 per family $250 per individual / $500 per family None $9,250 per individual / $18,500 per family Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians $45 50% Specialist physician office visits $65 50% Outpatient diagnostic X-ray and imaging $65 50% (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) $45 50% OUTPATIENT SERVICES Outpatient surgery in a hospital 20% 50% 5 The allowed 26 choosing your health plan

31 Outpatient surgery performed at an ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies Outpatient diagnostic X-ray and imaging performed in a hospital Outpatient diagnostic laboratory and pathology performed in a hospital 20% 50% 6 The allowed $300 per day. for 50% of this $300 per excess of $300 20% 50% 5 The allowed $65 50% 5 The allowed $45 50% 5 The allowed CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine 3 (prior authorization is required) 20% 50% 7 The allowed HOSPITALIZATION SERVICES Inpatient physician services 3 20% 50% Inpatient non-emergency facility services 3 (semi-private room and board, services and supplies, including subacute care) 20% 50% 5 The allowed Bariatric surgery (prior authorization is required; medically 20% necessary surgery for weight loss is for morbid obesity only) 3,8 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission 3 $250 $250 Emergency room services resulting in admission 3 (when the member is admitted directly from the ER) 20% 20% Emergency room physician services 20% 20% Urgent care $90 50% AMBULANCE SERVICES Emergency or authorized transport 3 (ground or air) $250 $250 PRESCRIPTION DRUG COVERAGE 9,10,11 Pharmacy Pharmacy Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 10 Generic drugs $15 per prescription choosing your health plan 27

32 Preferred brand drugs 3 $50 per prescription Non-preferred brand drugs 3 $70 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 10 Generic drugs $45 per prescription Preferred brand drugs 3 $150 per prescription Non-preferred brand drugs 3 $210 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs 3 20% (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) Oral Anti-cancer Medications 20% up to a of $200 PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) per prescription 20% 50% 20% 50% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 20% 50% MENTAL HEALTH SERVICES 12 Inpatient hospital services 3 (prior authorization required) 20% 50% 5 Outpatient mental health services (some services may require prior authorization and facility charges) The allowed $45 50% SUBSTANCE ABUSE SERVICES 12 Inpatient hospital services 3 (prior authorization required) 20% 50% 5 Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) The allowed $45 50% 20% (unless prior authorized) OTHER Pregnancy and Maternity Care s Prenatal physician office visits 50% Postnatal physician office visits $45 50% Inpatient hospital services for normal delivery and cesarean section 3 20% 50% 5 The allowed 28 choosing your health plan

33 Abortion services 13 20% 50% Family Planning s Injectable and implantable contraceptives Counseling and consulting Tubal ligation Vasectomy 20% Infertility services Rehabilitation and Habilitation s Office location $45 50% Outpatient department of a hospital $45 50% 5 The allowed Chiropractic s Chiropractic services Acupuncture s Acupuncture services $45 50% Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Child Dental Diagnostic and Preventive Oral exam No charge No charge 20% Preventive - cleaning No charge No charge 20% Preventive - X-ray No charge No charge 20% Sealants per tooth No charge No charge 20% Topical fluoride application No charge No charge 20% Caries risk management No charge No charge 20% Space maintainers - fixed No charge No charge 20% Child Dental Basic Services Amalgam fill - 1 surface No charge 20% 30% Child Dental Major Services 2 Root canal - molar No charge 50% 50% Gingivectomy per quad No charge 50% 50% Extraction - single tooth exposed root or No charge 50% 50% Extraction - complete bony No charge 50% 50% Porcelain with metal crown No charge 50% 50% Child Orthodontics 2 Medically necessary orthodontics No charge 50% 50% Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 14 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exam (92002/92004) - Established patient exam (92012/92014) Eyeglasses Covered up to a allowance of $30 2 Covered up to a allowance of $30 2 choosing your health plan 29

34 Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. Covered up to a allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating (standard only) Anti-reflective coating (standard only) $35 High-index lenses $30 Photochromic lenses (glass or plastic) $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame (one frame per calendar year) Collection frame Non-collection frame 15 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 16 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary Covered up to a allowance of $150 to 6 months) to 3 months) Covered up to a allowance $40 Covered up to a allowance of $75 Covered up to a allowance of $75 Covered up to a allowance of $75 Covered up to a allowance of $75 Covered up to a allowance of $225 for medically necessary contact lenses Other Pediatric Vision s Supplemental low-vision testing and equipment 17 35% Diabetes management referral Please Note: s are subject to modification for subsequently enacted state or federal legislation. Pediatric Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically 30 choosing your health plan

35 necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. Endnotes for Silver 70 PPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 Members enrolled in this plan can access benefits from any provider, including a Blue Shield participating provider, a nonparticipating provider, or a provider for s; however, there is no member cost-sharing for services received from a provider or pharmacy for s. s from a provider or pharmacy for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 After the calendar year medical deductible is met, the member is responsible for a copayment or coinsurance from participating providers. providers accept Blue Shield s allowable amounts as full payment for covered services. Non-participating providers can charge more than these amounts. The member is responsible for these charges in addition to the applicable copayment or coinsurance when accessing these providers, which amount can be substantial. Amounts applied to the calendar year deductible accrue towards the applicable out-of-pocket. Charges in excess of the allowable amount do not count toward the calendar year medical deductible or out-of-pocket. 3 The covered services listed below are subject to, and will accrue to the calendar year medical or brand drug deductibles. Ambulance benefits Bariatric surgery benefits: hospital inpatient services Emergency room benefits: emergency room services (facility) Hospital benefits (facility services): inpatient facility services, inpatient skilled nursing services including subacute care, and inpatient services to treat acute medical complications of detoxification Medical treatment for the teeth, gums, jaw joints, or jaw bones benefits: inpatient hospital services Mental health and substance abuse benefits: inpatient hospital services, and residential care Outpatient X-Ray, imaging, pathology, and laboratory benefits: radiological and nuclear imaging services Pregnancy and maternity care benefits: inpatient hospital services Reconstructive surgery benefits: inpatient hospital services Skilled nursing facility benefits Transplant benefits: inpatient hospital or facility services Preferred brand drugs, non-preferred brand drugs, and specialty drugs (subject to and accrues to the brand drug deductible) 4 Copayments or coinsurance for covered services apply toward the calendar year out-of-pocket, except copayments or coinsurance for the following: (a) charges in excess of specified benefit s; (b) covered travel expenses for bariatric surgery; and (c) dialysis center services from a non-participating provider. Copayments, coinsurance, and charges for services not accruing to the calendar year out-of-pocket continue to be the member s responsibility after the calendar year out-of-pocket is reached. 5 The allowable amount for non-emergency services and supplies received from a non-participating hospital or facility is limited to for the coinsurance and all charges that exceed 6 The allowable amount for non-emergency services and supplies received from an ambulatory surgery center is limited to $300 per day. for the coinsurance and all charges that exceed $300 per day. ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 7 The allowable amount for non-emergency services and supplies received from a non-participating radiology center is limited to $300 per day. for all charges that exceed $300 per day. The allowable amount for non-emergency services and supplies received from a non-participating hospital is limited to for all charges that exceed 8 Bariatric surgery is covered when prior authorized by Blue Shield. The member may access bariatric surgery from a Provider for no share-of-cost. If the member accesses the bariatric surgery benefit from a Blue Shield participating provider: (a) for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. (b) Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers (this exclusion is not applicable to Providers). (c) In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. (d) Refer to the Evidence of Coverage and Summary of s for details. choosing your health plan 31

36 9 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 Medicare Part D premium. 10 Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment and will not be subject to any calendar year brand drug deductible; however, if a brand contraceptive drug is requested when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year brand drug deductible, medical deductible, or the calendar year out-of-pocket responsibility. 11 If a member or physician requests a brand drug when a generic drug equivalent is available, and the calendar year brand drug deductible has been satisfied, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost that the member must pay does not accrue to any calendar year brand drug deductible, medical deductible, or the calendar year out-of-pocket responsibility. Refer to the Evidence of Coverage and Summary of s for details. 12 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for acute medical detoxification, through a separate network of MHSA participating providers. Inpatient acute medical detoxification is a medical benefit provided by Blue Shield participating or non-participating (not MHSA) providers. 13 Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), and additional facility copayment may apply. 14 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 15 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 16 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 17 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required. This plan is pending regulatory approval. 32 choosing your health plan

37 Silver 70 EPO AI-AN This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This EPO plan uses the EPO provider network. This exclusive provider organization (EPO) plan utilizes a network of Providers. Except for Emergency Services, Urgent Services, or when prior authorized by Blue Shield, all services must be obtained from Providers to be covered. Calendar Year Medical Deductible 3 (Services received from providers are not subject to a deductible. Services received from participating providers are subject to a deductible. For family coverage, an individual is responsible for satisfying their own individual deductible and that amount accumulates to the family deductible.) Calendar Year Out-of-Pocket Maximum 4 (Services received from providers are not subject to a calendar year out-of-pocket. Services received from participating providers are subject to a calendar year out-of-pocket. The calendar year out-of-pocket includes the calendar year medical deductible.) $2,000 per individual / $4,000 per family $6,250 per individual / $12,500 per family Calendar Year Brand Drug Deductible $250 per individual (Brand drugs received from pharmacies are not subject to the calendar year brand drug deductible. Brand drugs received from a Blue Shield participating pharmacy are subject to the calendar year brand drug deductible. For family coverage, an individual is responsible for satisfying their own individual deductible and that amount accumulates to the family deductible. The calendar year brand drug deductible is separate from the calendar year medical deductible and accrues to the calendar year out-ofpocket.) / $500 per family Lifetime Maximum None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians $45 Specialist physician office visits $65 Outpatient diagnostic X-ray and imaging $65 (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) $45 OUTPATIENT SERVICES Outpatient surgery in a hospital 20% Outpatient surgery performed at an ambulatory 20% surgery center 5 Outpatient services for treatment of illness or injury and necessary supplies 20% choosing your health plan 33

38 Outpatient diagnostic X-ray and imaging performed in $65 a hospital Outpatient diagnostic laboratory and pathology $45 performed in a hospital CT scans, MRIs, MRAs, PET scans, and cardiac 20% diagnostic procedures utilizing nuclear medicine 3 (prior authorization is required) HOSPITALIZATION SERVICES Inpatient physician services 20% Inpatient non-emergency facility services 3 20% (semi-private room and board, services and supplies, including subacute care) Bariatric surgery (prior authorization is required; medically 20% necessary surgery for weight loss is for morbid obesity only) 3,6 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission 3 $250 $250 Emergency room services resulting in admission 3 20% 20% (when the member is admitted directly from the ER) Emergency room physician services 20% 20% Urgent care $90 $90 AMBULANCE SERVICES Emergency or authorized transport 3 (ground or air) $250 $250 PRESCRIPTION DRUG COVERAGE 7,8,9 Pharmacy Pharmacy Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 8 Generic drugs $15 per prescription Preferred brand drugs 3 $50 per prescription Non-preferred brand drugs 3 $70 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 8 Generic drugs $45 per prescription Preferred brand drugs 3 $150 per prescription Non-preferred brand drugs 3 $210 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs 3 (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) 20% Oral Anti-cancer Medications 20% up to a of $200 per prescription PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) 20% 20% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 20% MENTAL HEALTH SERVICES 10 Inpatient hospital services 3 (prior authorization required) 20% Outpatient mental health services (some services may require prior authorization and facility charges) SUBSTANCE ABUSE SERVICES 10 $45 Inpatient hospital services 3 (prior authorization required) 20% Outpatient substance abuse services $45 (some services may require prior authorization and facility charges) 34 choosing your health plan

39 HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) 20% OTHER Pregnancy and Maternity Care s Prenatal physician office visits Postnatal physician office visits $45 Inpatient hospital services for normal delivery and 20% cesarean section 3 Abortion services 11 20% Family Planning s Injectable and implantable contraceptives Counseling and consulting Tubal ligation Vasectomy 20% Infertility services Rehabilitation and Habilitation s Office location $45 Outpatient department of a hospital $45 Chiropractic s Chiropractic services Acupuncture s Acupuncture services $45 Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Child Dental Diagnostic and Preventive Oral exam No charge No charge Preventive - cleaning No charge No charge Preventive - X-ray No charge No charge Sealants per tooth No charge No charge Topical fluoride application No charge No charge Caries risk management No charge No charge Space maintainers - fixed No charge No charge Child Dental Basic Services Amalgam fill - 1 surface No charge 20% Child Dental Major Services 2 Root canal - molar No charge 50% Gingivectomy per quad No charge 50% Extraction - single tooth exposed root or No charge 50% Extraction - complete bony No charge 50% Porcelain with metal crown No charge 50% Child Orthodontics 2 Medically necessary orthodontics No charge 50% Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exam (92002/92004) - Established patient exam (92012/92014) choosing your health plan 35

40 Eyeglasses Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. Optional Lenses and Treatments UV coating (standard only) Anti-reflective coating (standard only) $35 High-index lenses $30 Photochromic lenses (glass or plastic) $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame (one frame per calendar year) Collection frame Non-collection frame 13 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 14 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary Covered up to a allowance of $150 to 6 months) to 3 months) Other Pediatric Vision s Supplemental low-vision testing and equipment 14 35% Diabetes management referral Please Note: s are subject to modification for subsequently enacted state or federal legislation. Pediatric Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. 36 choosing your health plan

41 Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. Endnotes for Silver 70 EPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 There is no member cost-sharing for services received from a provider or pharmacy for s. s from a provider or pharmacy for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 After the calendar year deductible is met, the member is responsible for a copayment or coinsurance from participating providers. providers accept Blue Shield s allowable amounts as full payment for covered services. Amounts applied to your calendar year deductible accrue towards the out-of-pocket. for the full amount charged by nonparticipating providers. 3 The covered services listed below are subject to, and will accrue to the calendar year medical or brand drug deductibles. Ambulance benefits Bariatric surgery benefits: hospital inpatient services Emergency room benefits: emergency room services (facility) Hospital benefits (facility services): inpatient facility services, inpatient skilled nursing services including subacute care, and inpatient services to treat acute medical complications of detoxification Medical treatment for the teeth, gums, jaw joints, or jaw bones benefits: inpatient hospital services Mental health and substance abuse benefits: inpatient hospital services, and residential care Outpatient X-Ray, imaging, pathology, and laboratory benefits: radiological and nuclear imaging services Pregnancy and maternity care benefits: inpatient hospital services Reconstructive surgery benefits: inpatient hospital services Skilled nursing facility benefits Transplant benefits: inpatient hospital or facility services Preferred brand drugs, non-preferred brand drugs, and specialty drugs (subject to and accrues to the brand drug deductible) 4 Copayments or coinsurance for covered services apply toward the calendar year out-of-pocket, except copayments or coinsurance for the following: (a) charges in excess of specified benefit s; and (b) covered travel expenses for bariatric surgery. Copayments, coinsurance, and charges for services not accruing to the calendar year out-of-pocket continue to be the member s responsibility after the calendar year out-of-pocket is reached. 5 ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 6 Bariatric surgery is covered when prior authorized by Blue Shield. The member may access bariatric surgery from a Provider for no share-of-cost. If the member accesses the bariatric surgery benefit from a Blue Shield participating provider: (a) for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. (b) Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers (this exclusion is not applicable to Providers). (c) In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. (d) Refer to the Evidence of Coverage and Summary of s for details. 7 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 Medicare Part D premium. 8 Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment and will not be subject to any calendar year brand drug deductible; however, if a brand contraceptive drug is requested when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year brand drug deductible, medical deductible, or calendar year out-of-pocket responsibility. 9 If a member or physician requests a brand drug when a generic drug equivalent is available, and the calendar year brand drug deductible has been satisfied, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost that the member must pay does not accrue to any calendar year brand drug deductible, medical deductible, or calendar year out-of-pocket responsibility. Refer to the Evidence of Coverage and Summary of s for details. 10 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for acute medical detoxification, choosing your health plan 37

42 through a separate network of MHSA participating providers. Inpatient acute medical detoxification is a medical benefit provided by Blue Shield participating providers. 11 Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), and additional facility copayment may apply. 12 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 13 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 14 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required. This plan is pending regulatory approval. 38 choosing your health plan

43 Bronze 60 PPO AI-AN This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This PPO plan uses the Exclusive PPO provider network. Calendar Year Medical Deductible 3 (Services received from providers are not subject to a deductible. Services received from all other providers are subject to a deductible. For family coverage, an individual is responsible for satisfying their own individual deductible and that amount accumulates to the family deductible.) Medical deductible applies to all benefits except those in endnote 2. Calendar Year Out-of-Pocket Maximum 4 (Services received from providers are not subject to a calendar year out-of-pocket. Services received from all other providers are subject to a calendar year out-of-pocket. The calendar year out-of-pocket includes the calendar year medical deductible. Copayments for participating providers apply to both participating and non-participating provider calendar year out-of-pocket amounts.) Calendar Year Brand Drug Deductible (Brand drugs received from pharmacies are not subject to any deductible. Brand drugs received from a Blue Shield participating pharmacy are subject to the calendar year medical deductible.) Lifetime Maximum $5,000 per individual / $10,000 per family (all providers combined) $6,250 per individual / $12,500 per family $9,250 per individual / $18,500 per family None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians (visit limit is a combination of any physician office visits, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visits) $60 for first 3 visits per calendar year prior to deductible 3, then $60 after deductible Specialist physician office visits $70 50% Outpatient diagnostic X-ray and imaging 30% 50% (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) 50% 30% 50% 3 OUTPATIENT SERVICES Outpatient surgery in a hospital 30% 50% 5 The allowed Members are responsible for 50% of this $500 per day, plus all charges in excess of $500 choosing your health plan 39

44 Outpatient surgery performed at an ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies Outpatient diagnostic X-ray and imaging performed in a hospital Outpatient diagnostic laboratory and pathology performed in a hospital 30% 50% 6 The allowed $300 per day. Members are responsible for 50% of this $300 per day, plus all charges in excess of $300 30% 50% 5 The allowed Members are responsible for 50% of this $500 per day, plus all charges in excess of $500 30% 50% 5 The allowed Members are responsible for 50% of this $500 per day, plus all charges in excess of $500 30% 50% 5 The allowed Members are responsible for 50% of this $500 per day, plus all charges in excess of $500 CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required) 30% 50% 7 The allowed HOSPITALIZATION SERVICES Inpatient physician services 30% 50% Inpatient non-emergency facility services (semi-private room and board, services and supplies, including subacute care) 30% 50% 5 The allowed Bariatric surgery (prior authorization is required; medically 30% necessary surgery for weight loss is for morbid obesity only) 8 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission $300 $300 Emergency room services resulting in admission 30% 30% (when the member is admitted directly from the ER) Emergency room physician services 30% 30% 40 choosing your health plan

45 Urgent care (visit limit is a combination of any physician office visits, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visits) $120 for first 3 visits per calendar year prior to deductible 3, then $120 after deductible 50% AMBULANCE SERVICES Emergency or authorized transport (ground or air) $300 $300 PRESCRIPTION DRUG COVERAGE 9,10,11 Pharmacy 1 Pharmacy Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 3,10 Generic drugs $15 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $75 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 3,10 Generic drugs $45 per prescription Preferred brand drugs $150 per prescription Non-preferred brand drugs $225 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) 30% Oral Anti-cancer Medications 30% up to a of $200 per prescription PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) 30% 50% 30% 50% DURABLE MEDICAL EQUIPMENT Breast pump 3 Other durable medical equipment 30% 50% MENTAL HEALTH SERVICES 12 Inpatient hospital services (prior authorization required) 30% 50% 5 Outpatient mental health services (visit limit is a combination of any physician office visits, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visits; some services may require prior authorization and facility charges) $60 for first 3 visits per calendar year prior to deductible 3, then $60 after deductible The allowed SUBSTANCE ABUSE SERVICES 12 Inpatient hospital (prior authorization required) 30% 50% 5 50% The allowed choosing your health plan 41

46 Outpatient substance abuse services (visit limit is a combination of any physician office visits, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visits; some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) OTHER Pregnancy and Maternity Care s $60 for first 3 visits per calendar year prior to deductible 3, then $60 after deductible 50% 30% (unless prior authorized) Prenatal physician office visits 3 50% Postnatal physician office visits (visit limit is a combination of any physician office visits, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visits) 50% $60 for first 3 visits per calendar year prior to deductible 3, then $60 after deductible Inpatient hospital services for normal delivery and cesarean section 30% 50% 5 The allowed Abortion services 13 30% 50% Family Planning s Injectable and implantable contraceptives 3 Counseling and consulting 3 Tubal ligation 3 Vasectomy 30% Infertility services Rehabilitation and Habilitation s Office location $60 50% Outpatient department of a hospital $60 50% 5 The allowed Chiropractic s Chiropractic services Acupuncture s Acupuncture services $60 50% Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency and non emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Child Dental Diagnostic and Preventive Oral exam No charge No charge 20% Preventive - cleaning No charge No charge 20% Preventive - X-ray No charge No charge 20% 42 choosing your health plan

47 Sealants per tooth No charge No charge 20% Topical fluoride application No charge No charge 20% Caries risk management No charge No charge 20% Space maintainers - fixed No charge No charge 20% Child Dental Basic Services Amalgam fill - 1 surface No charge 20% 30% Child Dental Major Services 2 Root canal - molar No charge 50% 50% Gingivectomy per quad No charge 50% 50% Extraction - single tooth exposed root or No charge 50% 50% Extraction - complete bony No charge 50% 50% Porcelain with metal crown No charge 50% 50% Child Orthodontics 2 Medically necessary orthodontics No charge 50% 50% Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 14 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exam (92002/92004) - Established patient exam (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. 3 Covered up to a allowance of $ Covered up to a allowance of $ Covered up to a allowance of: $25 single vision 3 $35 lined bifocal 3 $45 lined trifocal 3 $45 lenticular 3 Optional Lenses and Treatments UV coating (standard only) 3 Anti-reflective coating (standard only) $35 3 High-index lenses $30 3 Photochromic lenses (glass or plastic) $25 3 Polarized lenses $45 3 Standard progressives $55 3 Premium progressives $95 3 Frame (one frame per calendar year) Collection frame Non-collection frame 15 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 16 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) 3 Covered up to a allowance of $ to 6 months) 3 Covered up to a allowance $40 3 Covered up to a allowance of $75 3 Covered up to a allowance of $75 3 Covered up to a allowance of $75 3 choosing your health plan 43

48 Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary 3 to 3 months) 3 Covered up to a allowance of $75 3 Covered up to a allowance of $225 for medically necessary contact lenses 3 Other Pediatric Vision s Supplemental low-vision testing and equipment 17 35% 3 Diabetes management referral 3 Please Note: s are subject to modification for subsequently enacted state or federal legislation. Pediatric Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. Endnotes for Bronze 60 PPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 Members enrolled in this plan can access benefits from any provider, including a Blue Shield participating provider, a nonparticipating provider, or a provider for s; however, there is no member cost-sharing for services received from a provider or pharmacy for s. s from a provider or pharmacy for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 After the calendar year medical deductible is met, the member is responsible for a copayment or coinsurance from participating providers. providers accept Blue Shield s allowable amounts as full payment for covered services. Non-participating providers can charge more than these amounts. The member is responsible for these charges in addition to the applicable copayment or coinsurance when accessing these providers, which amount can be substantial. Amounts applied to the calendar year deductible accrue towards the applicable out-of-pocket. Charges in excess of the allowable amount do not count toward the calendar year medical deductible or out-of-pocket. 3 The covered services listed below are not subject to, and will not accrue to the calendar year medical deductible. First dollar coverage: first three physician office visits Durable medical equipment: breast pump Family planning benefits: counseling and consulting; diaphragm fitting procedure; implantable contraceptives; injectable contraceptives; insertion and/or removal of IUD device; IUD; and tubal ligation Outpatient prescription drug benefits: contraceptive drugs and devices Pediatric vision benefits 44 choosing your health plan

49 Pregnancy and maternity care benefits: prenatal and preconception physician office visits Preventive health services Pediatric dental benefits 4 Copayments or coinsurance for covered services apply toward the calendar year out-of-pocket, except copayments or coinsurance for the following: (a) charges in excess of specified benefit s; (b) covered travel expenses for bariatric surgery; and (d) dialysis center services from a non-participating provider. Copayments, coinsurance, and charges for services not accruing to the calendar year out-of-pocket continue to be the member s responsibility after the calendar year out-of-pocket is reached. 5 The allowable amount for non-emergency services and supplies received from a non-participating hospital or facility is limited to for the coinsurance and all charges that exceed 6 The allowable amount for non-emergency services and supplies received from an ambulatory surgery center is limited to $300 per day. for the coinsurance and all charges that exceed $300 per day. ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 7 The allowable amount for non-emergency services and supplies received from a non-participating radiology center is limited to $300 per day. for all charges that exceed $300 per day. The allowable amount for non-emergency services and supplies received from a non-participating hospital is limited to for all charges that exceed 8 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage and Summary of s for details. 9 This plan s prescription drug coverage provides less coverage on average than the standard benefit set by the federal government for Medicare Part D (also called non-creditable coverage). It is important to know that generally you may only enroll in a Medicare Part D plan from October 15th through December 7th of each year. If you do not enroll in a Medicare Part D plan when you are first eligible to join, you may be subject to a late enrollment penalty in addition to your Part D premium when you enroll at a later date. For more information about your current plan s prescription drug coverage, call the Customer Service telephone number on your identification card, Monday through Thursday between 8:00 a.m. and 5:00 p.m. or on Friday between 9:00 a.m. and 5:00 p.m. The hearing impaired may call the TTY number at (888) Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment and will not be subject to any calendar year medical deductible; however, if a brand contraceptive drug is requested when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year medical deductible or outof-pocket responsibility. 11 If a member or physician requests a brand drug when a generic drug equivalent is available, and the calendar year medical deductible has been satisfied, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost that the member must pay does not accrue to any calendar year medical deductible or out-of-pocket responsibility. Refer to the Evidence of Coverage and Summary of s for details. 12 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for acute medical detoxification, through a separate network of MHSA participating providers. Inpatient acute medical detoxification is a medical benefit provided by Blue Shield participating or non-participating (not MHSA) providers. 13 Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 14 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 15 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 16 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 17 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required. This plan is pending regulatory approval. choosing your health plan 45

50 Bronze 60 EPO AI-AN This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This EPO plan uses the EPO provider network. This exclusive provider organization (EPO) plan utilizes a network of Providers. Except for Emergency Services, Urgent Services, or when prior authorized by Blue Shield, all services must be obtained from Providers to be covered. Calendar Year Medical Deductible 3 (Services received from providers are not subject to a deductible. Services received from participating providers are subject to a deductible. For family coverage, an individual is responsible for satisfying their own individual deductible and that amount accumulates to the family deductible.) Medical deductible applies to all benefits except those in endnote 2. Calendar Year Out-of-Pocket Maximum 4 (Services received from providers are not subject to a calendar year out-of-pocket. Services received from participating providers are subject to a calendar year out-of-pocket. The calendar year out-of-pocket includes the calendar year medical deductible.) $5,000 per individual / $10,000 per family $6,250 per individual / $12,500 per family Calendar Year Brand Drug Deductible (Brand drugs received from pharmacies are not subject to any deductible. Brand drugs received from a Blue Shield participating pharmacy are subject to the calendar year medical deductible.) Lifetime Maximum None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians (visit limit is a combination of any physician office visits, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visits) $60 for first 3 visits per calendar year prior to deductible 3, then $60 after deductible Specialist physician office visits $70 Outpatient diagnostic X-ray and imaging 30% (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) 30% 3 OUTPATIENT SERVICES Outpatient surgery in a hospital 30% Outpatient surgery performed at an ambulatory 30% surgery center 5 Outpatient services for treatment of illness or injury 30% and necessary supplies Outpatient diagnostic X-ray and imaging performed in a hospital 30% 46 choosing your health plan

51 Outpatient diagnostic laboratory and pathology 30% performed in a hospital CT scans, MRIs, MRAs, PET scans, and cardiac 30% diagnostic procedures utilizing nuclear medicine (prior authorization is required) HOSPITALIZATION SERVICES Inpatient physician services 30% Inpatient non-emergency facility services 30% (semi-private room and board, services and supplies, including subacute care) Bariatric surgery (prior authorization is required; medically 30% necessary surgery for weight loss is for morbid obesity only) 6 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission $300 $300 Emergency room services resulting in admission 30% 30% (when the member is admitted directly from the ER) Emergency room physician services 30% 30% Urgent care (visit limit is a combination of any physician office visits, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visits) $120 for first 3 visits per calendar year prior to deductible 3, then $120 after deductible $120 for first 3 visits per calendar year prior to deductible 3, then $120 after deductible AMBULANCE SERVICES Emergency or authorized transport (ground or air) $300 $300 PRESCRIPTION DRUG COVERAGE 7,8,9 Pharmacy Pharmacy Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 3,8 Generic drugs $15 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $75 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 3,8 Generic drugs $45 per prescription Preferred brand drugs $150 per prescription Non-preferred brand drugs $225 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) 30% Oral Anti-cancer Medications 30% up to a of $200 per prescription PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) 30% 30% DURABLE MEDICAL EQUIPMENT Breast pump 3 Other durable medical equipment 30% MENTAL HEALTH SERVICES 10 Inpatient hospital services (prior authorization required) 30% Outpatient mental health services (visit limit is a combination of any physician office visits, urgent care, $60 for first 3 visits choosing your health plan 47

52 outpatient mental health, outpatient substance abuse, and postnatal visits; some services may require prior authorization and facility charges) per calendar year prior to deductible 3, then $60 after deductible SUBSTANCE ABUSE SERVICES 10 Inpatient hospital services (prior authorization required) 30% Outpatient substance abuse services (visit limit is a combination of any physician office visits, urgent care, outpatient mental health, outpatient substance abuse, and postnatal visits; some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) OTHER Pregnancy and Maternity Care s $60 for first 3 visits per calendar year prior to deductible 3, then $60 after deductible 30% Prenatal physician office visits 3 Postnatal physician office visits (visit limit is a combination of any physician office visits, urgent care, outpatient mental health, behavioral health, outpatient substance abuse, and postnatal visits) $60 for first 3 visits per calendar year prior to deductible 3, then $60 after deductible Inpatient hospital services for normal delivery and 30% cesarean section Abortion services 11 30% Family Planning s Injectable and implantable contraceptives 3 Counseling and consulting 3 Tubal ligation 3 Vasectomy 30% Infertility services Rehabilitation and Habilitation s Office location $60 Outpatient department of a hospital $60 Chiropractic s Chiropractic services Acupuncture s Acupuncture services $60 Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Child Dental Diagnostic and Preventive Oral exam No charge No charge Preventive - cleaning No charge No charge Preventive - X-ray No charge No charge Sealants per tooth No charge No charge Topical fluoride application No charge No charge Caries risk management No charge No charge Space maintainers - fixed No charge No charge Child Dental Basic Services Amalgam fill - 1 surface No charge 20% 48 choosing your health plan

53 Child Dental Major Services 2 Root canal - molar No charge 50% Gingivectomy per quad No charge 50% Extraction - single tooth exposed root or No charge 50% Extraction - complete bony No charge 50% Porcelain with metal crown No charge 50% Child Orthodontics 2 Medically necessary orthodontics No charge 50% Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) 3 Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exam (92002/92004) - Established patient exam (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. 3 3 Optional Lenses and Treatments UV coating (standard only) 3 Anti-reflective coating (standard only) $35 3 High-index lenses $30 3 Photochromic lenses (glass or plastic) $25 3 Polarized lenses $45 3 Standard progressives $55 3 Premium progressives $95 3 Frame (one frame per calendar year) Collection frame Non-collection frame 13 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 14 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary 3 Covered up to a allowance of $ to 6 months) 3 3 to 3 months) 3 Other Pediatric Vision s Supplemental low-vision testing and equipment 15 35% 3 Diabetes management referral 3 choosing your health plan 49

54 Please Note: s are subject to modification for subsequently enacted state or federal legislation. Pediatric Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. Endnotes for Bronze 60 EPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 There is no member cost-sharing for services received from a provider or pharmacy for s. s from a provider or pharmacy for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 After the calendar year medical deductible is met, the member is responsible for a copayment or coinsurance from participating providers. providers accept Blue Shield s allowable amounts as full payment for covered services. There is no nonemergency coverage for non-participating providers under the plan. for the full amount charged by nonparticipating providers. 3 The covered services listed below are not subject to, and will not accrue to the calendar year medical deductible. First dollar coverage: first three physician office visits Durable medical equipment: breast pump Family planning benefits: counseling and consulting; diaphragm fitting procedure; implantable contraceptives; injectable contraceptives; insertion and/or removal of IUD device; IUD; and tubal ligation Outpatient prescription drug benefits: contraceptive drugs and devices Pediatric vision benefits Pregnancy and maternity care benefits: prenatal and preconception physician office visits Preventive health services Pediatric dental benefits 4 Copayments or coinsurance for covered services apply toward the calendar year out-of-pocket, except copayments or coinsurance for the following: (a) charges in excess of specified benefit s; and (b) covered travel expenses for bariatric surgery. Copayments, coinsurance, and charges for services not accruing to the calendar year out-of-pocket continue to be the member s responsibility after the calendar year out-of-pocket is reached. 5 ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 6 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage and Summary of s for details. 7 This plan s prescription drug coverage provides less coverage on average than the standard benefit set by the federal government for Medicare Part D (also called non-creditable coverage). It is important to know that generally you may only enroll in a Medicare Part D plan from October 15th through December 7th of each year. If you do not enroll in a Medicare Part D plan when you are first eligible to join, you may be subject to a late enrollment penalty in addition to your Part D premium when you enroll at a later date. For 50 choosing your health plan

55 more information about your current plan s prescription drug coverage, call the Customer Service telephone number on your identification card, Monday through Thursday between 8:00 a.m. and 5:00 p.m. or on Friday between 9:00 a.m. and 5:00 p.m. The hearing impaired may call the TTY number at (888) Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment and will not be subject to any calendar year medical deductible; however, if a brand contraceptive drug is requested when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year medical deductible or outof-pocket responsibility. 9 If a member or physician requests a brand drug when a generic drug equivalent is available, and the calendar year medical deductible has been satisfied, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost that the member must pay does not accrue to any calendar year medical deductible or out-of-pocket responsibility. Refer to the Evidence of Coverage and Summary of s for details. 10 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for acute medical detoxification, through a separate network of MHSA participating providers. Inpatient acute medical detoxification is a medical benefit provided by Blue Shield participating or non-participating (not MHSA) providers. 11 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 12 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 13 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 14 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required. This plan is pending regulatory approval. choosing your health plan 51

56 Cost Share PPO AI-AN This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This PPO plan does not require the use of a provider network. Any Provider 1 Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum Calendar Year Brand Drug Deductible Lifetime Maximum None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians Any Provider 1 Specialist physician office visits Outpatient diagnostic X-ray and imaging (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) OUTPATIENT SERVICES Outpatient surgery in a hospital Outpatient surgery performed at an ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies Outpatient diagnostic X-ray and performed in a hospital Outpatient diagnostic laboratory and pathology performed in a hospital CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required) HOSPITALIZATION SERVICES Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, services and supplies, including subacute care) Bariatric surgery (prior authorization is required; medically necessary surgery for weight loss is for morbid obesity only) 2 EMERGENCY HEALTH COVERAGE 52 choosing your health plan

57 Emergency room services not resulting in admission Emergency room services resulting in admission (when the member is admitted directly from the ER) Any Provider 1 Emergency room physician services Urgent care AMBULANCE SERVICES Emergency or authorized transport (ground or air) PRESCRIPTION DRUG COVERAGE 3 Any Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) Oral Anti-cancer Medications Any Provider 1 PROSTHETICS/ORTHOTICS Prosthetic equipment and devices Orthotic equipment and devices DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment MENTAL HEALTH SERVICES Inpatient hospital services (prior authorization required) Outpatient mental health services (some services may require prior authorization and facility charges) SUBSTANCE ABUSE SERVICES Inpatient hospital (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) OTHER Pregnancy and Maternity Care s Prenatal physician office visits Postnatal physician office visits Inpatient hospital services for normal delivery and cesarean section Abortion services Family Planning s Injectable and implantable contraceptives Counseling and consulting choosing your health plan 53

58 Any Provider 1 Tubal ligation Vasectomy Infertility services Rehabilitation and Habilitation s Office location Outpatient department of a hospital Chiropractic s Chiropractic services Acupuncture s Acupuncture services Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Outside of US: BlueCard Worldwide See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Child Dental Diagnostic and Preventive Oral exam No charge Preventive - cleaning No charge Preventive - X-ray No charge Sealants per tooth No charge Topical fluoride application No charge Caries risk management No charge Space maintainers - fixed No charge Child Dental Basic Services Amalgam fill - 1 surface No charge Child Dental Major Services 2 Root canal - molar No charge Gingivectomy per quad No charge Extraction - single tooth exposed No charge root or Extraction - complete bony No charge Porcelain with metal crown No charge Child Orthodontics 2 Medically necessary orthodontics Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 4 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V ) - Conventional (Lined) bifocal (V ) - Conventional (Lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glassgrey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. No charge Optional Lenses and Treatments UV coating (standard only) Anti-reflective coating (standard only) 54 choosing your health plan

59 Any Provider 1 High-index lenses Photochromic lenses (glass or plastic) Polarized lenses Standard progressives Premium progressives Frame (one frame per calendar year) Collection frame Non-collection frame 5 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 6 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary Other Pediatric Vision s Supplemental low-vision testing and equipment 7 Diabetes management referral Please Note: s are subject to modification for subsequently enacted state or federal legislation. Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. choosing your health plan 55

60 Endnotes for Cost Share PPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 There is no member cost-sharing for s covered under this health plan. Members enrolled in this plan can access benefits from any provider, including a Blue Shield participating provider, a non-participating provider, or a provider for Native Americans. s from a provider for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 Bariatric surgery is covered when prior authorized by Blue Shield. Refer to the Evidence of Coverage and Summary of s for further benefit details. 3 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 Medicare Part D premium. 4 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 5 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 6 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 7 A report from the provider and prior authorization from the Vision Plan Administrator is required. This plan is pending regulatory approval. 56 choosing your health plan

61 Cost Share EPO AI-AN This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This EPO plan uses the EPO provider network. This exclusive provider organization (EPO) plan utilizes a network of Providers. Except for Emergency Services, Urgent Services, or when prior authorized by Blue Shield, all services must be obtained from Providers to be covered. Calendar Year Medical Deductible (Services received from providers are not subject to a deductible. Services received from participating providers are subject to a deductible. For family coverage, an individual is responsible for satisfying their own individual deductible and that amount accumulates to the family deductible.) Calendar Year Out-of-Pocket Maximum (Services received from providers are not subject to a calendar year out-of-pocket. Services received from participating providers are subject to a calendar year out-of-pocket. The calendar year out-of-pocket includes the calendar year medical deductible.) Calendar Year Brand Drug Deductible (Brand drugs received from pharmacies are not subject to the calendar year brand drug deductible. Brand drugs received from a Blue Shield participating pharmacy are subject to the calendar year brand drug deductible. The calendar year brand drug deductible is separate from the calendar year medical deductible and accrues to the calendar year out-of-pocket.) Lifetime Maximum None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians Specialist physician office visits Outpatient diagnostic X-ray and imaging (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) OUTPATIENT SERVICES Outpatient surgery in a hospital Outpatient surgery performed at an ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies Outpatient diagnostic X-ray and imaging performed in a hospital Outpatient diagnostic laboratory and pathology performed in a hospital choosing your health plan 57

62 CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required) HOSPITALIZATION SERVICES Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, services and supplies, including subacute care) Bariatric surgery (prior authorization is required; medically necessary surgery for weight loss is for morbid obesity only) 3 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission Emergency room services resulting in admission (when the member is admitted directly from the ER) Emergency room physician services Urgent care AMBULANCE SERVICES Emergency or authorized transport (ground or air) PRESCRIPTION DRUG COVERAGE 4 Pharmacy Pharmacy 10 Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) Oral Anti-cancer Medications PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment MENTAL HEALTH SERVICES 5 Inpatient hospital services (prior authorization required) Outpatient mental health services (some services may require prior authorization and facility charges) SUBSTANCE ABUSE SERVICES 5 Inpatient hospital (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) OTHER Pregnancy and Maternity Care s Prenatal physician office visits Postnatal physician office visits Inpatient hospital services for normal delivery and 58 choosing your health plan

63 cesarean section Abortion services Family Planning s Injectable and implantable contraceptives Counseling and consulting Tubal ligation Vasectomy Infertility services Rehabilitation and Habilitation s Office location Outpatient department of a hospital Chiropractic s Chiropractic services Acupuncture s Acupuncture services Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Child Dental Diagnostic and Preventive Oral exam No charge No charge Preventive - cleaning No charge No charge Preventive - X-ray No charge No charge Sealants per tooth No charge No charge Topical fluoride application No charge No charge Caries risk management No charge No charge Space maintainers - fixed No charge No charge Child Dental Basic Services Amalgam fill - 1 surface No charge No charge Child Dental Major Services 2 Root canal - molar No charge No charge Gingivectomy per quad No charge No charge Extraction - single tooth exposed root or No charge No charge Extraction - complete bony No charge No charge Porcelain with metal crown No charge No charge Child Orthodontics 2 Medically necessary orthodontics Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 6 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exam (92002/92004) - Established patient exam (92012/92014) Eyeglasses choosing your health plan 59

64 Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. Optional Lenses and Treatments UV coating (standard only) Anti-reflective coating (standard only) High-index lenses Photochromic lenses (glass or plastic) Polarized lenses Standard progressives Premium progressives Frame (one frame per calendar year) Collection frame Non-collection frame 7 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Covered up to a allowance of $150 Contact Lenses 8 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary to 6 months) to 3 months) Other Pediatric Vision s Supplemental low-vision testing and equipment 9 Diabetes management referral Please Note: s are subject to modification for subsequently enacted state or federal legislation. Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities 60 choosing your health plan

65 Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. Endnotes for Cost Share EPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 There is no member cost-sharing for services received from a provider or pharmacy for s under this health plan. s from a provider for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 providers accept Blue Shield s allowable amounts as full payment for covered services. There is no non-emergency coverage for non-participating providers under the plan. for the full amount charged by non-participating providers. 3 Bariatric surgery is covered when prior authorized by Blue Shield. The member may access bariatric surgery from a Provider for no share-of-cost. If the member accesses the bariatric surgery benefit from a Blue Shield participating provider: (a) for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. (b) Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers (this exclusion is not applicable to Providers). (c) In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. (d) Refer to the Evidence of Coverage and Summary of s for details. 4 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 Medicare Part D premium. 5 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for medical acute detoxification, through a separate network of MHSA participating providers. Inpatient medical acute detoxification is a medical benefit provided by Blue Shield participating providers. The member may also access this benefit from a provider for no share-of-cost. 6 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 7 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 8 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 9 A report from the provider and prior authorization from the Vision Plan Administrator is required. This plan is pending regulatory approval. choosing your health plan 61

66 HSA-eligible, high-deductible health plans HSA-eligible PPO/EPO plans at a glance HSA-eligible plans are high-deductible health plans (HDHPs) that meet current health savings account (HSA) eligibility requirements. An HSA-eligible, HDHP offers affordable coverage and the option to open an HSA so you can plan ahead and put tax-advantaged money aside for healthcare expenses.* Additional highlights include: Preventive care services without a copayment before meeting the annual deductible Compatible with an HSA, so you can enjoy potential tax savings* 100% coverage for covered in-network services after meeting the annual out-of-pocket Our HSA-eligible PPO plan is available in the following counties Contra Costa El Dorado Fresno Imperial Inyo Kern Kings Los Angeles Madera Mariposa Merced Mono Orange County Placer Riverside Sacramento San Bernardino San Diego San Francisco San Joaquin San Luis Obispo San Mateo Santa Barbara Santa Clara Stanislaus Tulare Ventura Yolo Our HSA-eligible EPO plan is available in the following counties Alameda Amador Butte Calaveras Colusa Del Norte Glenn Humboldt Lake Lassen Marin Mendocino Modoc Napa Nevada Plumas San Benito Santa Cruz Shasta Sierra Siskiyou Solano Sonoma Tehama Trinity Tuolumne The Blue Shield HSA-eligible EPO plan is not available in the following ZIP codes for the following counties: Alameda: 94505, 94514, 94536, 94538, 94539, 94555, 94560, 94583, 94586, 94587, 95035, 95304, 95377, Amador: 95629, 95644, 95646, 95666, 95669, Butte: 95901, 95914, 95925, 95930, 95941, 95942, Calaveras: 95223, 95224, 95228, 95229, 95230, 95232, 95233, 95236, 95245, 95247, 95248, 95251, 95254, 95255, Colusa: 95645, 95939, 95955, 95957, 95979, Del Norte: 00049, 95543, Glenn: 00047, 95920, 95939, 95951, Humboldt: 00050, 00054, 95514, 95526, 95528, 95546, 95549, 95550, 95552, 95554, 95555, 95556, 95558, 95563, 95565, 95569, 95570, 95571, 95573, 95587, Lake: 00048, 95423, Lassen: 00012, 00019, 96006, 96009, 96056, 96068, 96109, 96113, 96114, 96117, 96119, 96121, 96123, 96128, 96132, Marin: 94929, 94937, 94940, Mendocino: 00022, 95410, 95415, 95417, 95425, 95427, 95428, 95429, 95432, 95445, 95449, 95454, 95459, 95463, 95466, 95468, 95469, 95488, 95494, 95585, 95587, Modoc: 96006, 96015, 96054, 96056, 96108, 96110, 96112, 96116, Nevada: 95602, 95728, 95959, 95960, 95977, 95986, Plumas: 00028, 00031, 95915, 95947, 95980, 95981, 95983, San Benito: 93210, 93925, 93930, 95004, 95020, Santa Cruz: 94060, 95006, 95017, Shasta: 96008, 96011, 96013, 96017, 96022, 96033, 96040, 96047, 96051, 96056, 96059, 96062, 96065, 96069, 96070, 96071, 96076, 96084, 96088, Sierra: 00033, 00065, 95960, 96118, 96124, Siskiyou: 00034, 00035, 95568, 96014, 96023, 96027, 96031, 96032, 96034, 96037, 96039, 96044, 96050, 96057, 96058, 96064, 96085, 96086, 96091, 96094, Solano: 94512, 94533, 94535, 94571, 94585, 95616, 95618, 95620, 95625, 95687, 95688, 95690, 95694, Sonoma: 95412, 95421, 95425, 95450, 95480, 95486, Tehama: 00037, 00038, 95963, 96021, 96022, 96029, 96059, 96061, 96074, 96075, 96076, Trinity: 00039, 00055, 95526, 95527, 95543, 95552, 95563, 95595, 96041, 96046, 96076, Tuolumne: 00040, 95230, 95305, 95311, 95321, 95329, 95335, 95364, * Although most consumers 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 or HSAs. HSAs are offered through financial institutions. For more information about HSAs, eligibility, and the law s current provisions, ask your financial or tax adviser. 62 choosing your health plan

67 Provider network The HSA-eligible PPO/EPO health plans offered by Blue Shield of California use the Exclusive PPO and EPO Networks. These networks consist of participating doctors and hospitals. Visit blueshieldca.com/fap to see if your provider is in one of our networks. Access to care and limitations Members who receive care from a provider in their plan s provider network are responsible for meeting the plan s calendar-year deductible and copayments or coinsurance up to the calendar year out-ofpocket for covered services. Members who receive care from an American Indian or Alaska Native provider are not required to meet a deductible, and will pay out of pocket when accessing covered benefits. A PPO plan provides access to an Exclusive Network of participating doctors, specialists, and hospitals. Members have the freedom to see any doctor in our Exclusive PPO Network, or any American Indian or Alaska Native provider, without a referral. Members have the option to receive care from non-participating providers, but are then responsible for meeting their plan s non-participating provider calendar-year deductible (if applicable), the copayment or coinsurance up to the non-participating provider calendaryear out of pocket, and all charges that exceed Blue Shield s allowable amount. An EPO plan provides access to a network of participating doctors, specialists, and hospitals. Members have the freedom to see any doctor in our EPO Network, or any American Indian or Alaska Native provider, without a referral. However, there s no coverage for services received from non-participating providers, except urgent and emergency care services. Members who receive non-urgent or non-emergency care from non-participating providers are responsible for all billed charges. The EPO Network and the Exclusive PPO Network fewer providers than Blue Shield s Full PPO Network. Certain healthcare services may not be available in your area. You may be required to travel in excess of 30 minutes to access these services. choosing your health plan 63

68 Bronze 60 HSA PPO AI-AN (HSA-Compatible) This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This PPO plan uses the Exclusive PPO provider network. Calendar Year Medical Deductible 3 (Services received from providers are not subject to a deductible. Services received from all other providers are subject to a deductible. For family coverage, there is no individual deductible. Enrolled family members receive benefits for covered services once the family deductible has been satisfied by one, or any combination of family members. Medical deductible applies to all benefits except those in endnote 3.) Calendar Year Out-of-Pocket Maximum 4 (Services received from providers are not subject to a calendar year out-of-pocket. Services received from all other providers are subject to a calendar year out-of-pocket. The calendar year out-of-pocket includes the calendar year medical deductible. Copayments for participating providers apply to both participating and non-participating provider calendar year out-of-pocket amounts.) Calendar Year Brand Drug Deductible (Brand drugs received from pharmacies are not subject to the calendar year brand drug deductible. Brand drugs received from a Blue Shield participating pharmacy are subject to the calendar year medical deductible.) Lifetime Maximum $4,500 for individuals / $9,000 for families (all providers combined) $6,250 for individuals / $12,500 for families $9,250 for individuals / $18,500 for families None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians 40% 50% Specialist physician office visits 40% 50% Outpatient diagnostic X-ray and imaging 40% 50% (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) 40% 50% 3 OUTPATIENT SERVICES Outpatient surgery in a hospital 40% 50% 5 The allowed 64 choosing your health plan

69 Outpatient surgery performed at an ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies Outpatient diagnostic X-ray and imaging performed in a hospital Outpatient diagnostic laboratory and pathology performed in a hospital CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required) 40% 50% 6 The allowed $300 per day. for 50% of this $300 per excess of $300 40% 50% 5 The allowed 40% 50% 5 The allowed 40% 50% 5 The allowed 40% 50% 7 The allowed HOSPITALIZATION SERVICES Inpatient physician services 40% 50% Inpatient non-emergency facility services (semi-private room and board, services and supplies, including subacute care) 40% 50% 5 The allowed Bariatric surgery (prior authorization is required; medically 40% necessary surgery for weight loss is for morbid obesity only) 8 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission 40% 40% Emergency room services resulting in admission (when the member is admitted directly from the ER) 40% 40% Emergency room physician services 40% 40% Urgent care 40% 50% AMBULANCE SERVICES Emergency or authorized transport (ground or air) 40% 40% PRESCRIPTION DRUG COVERAGE 9,10,11 Pharmacy 1 Pharmacy Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 3,10 Generic drugs 40% per prescription choosing your health plan 65

70 Preferred brand drugs 40% per prescription Non-preferred brand drugs 40% per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 3,10 Generic drugs 40% per prescription Preferred brand drugs 40% per prescription Non-preferred brand drugs 40% per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs 40% (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) Oral Anti-cancer Medications 40% up to a of $200 PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) per prescription 40% 50% 40% 50% DURABLE MEDICAL EQUIPMENT Breast pump 3 Other durable medical equipment 40% 50% MENTAL HEALTH SERVICES 12 Inpatient hospital services (prior authorization required) 40% 50% 5 Outpatient mental health services (some services may require prior authorization and facility charges) The allowed 40% 50% SUBSTANCE ABUSE SERVICES 12 Inpatient hospital services (prior authorization required) 40% 50% 5 Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) The allowed 40% 50% 40% (unless prior authorized) OTHER Pregnancy and Maternity Care s Prenatal physician office visits 3 50% Postnatal physician office visits 40% 50% Inpatient hospital services for normal delivery and cesarean section 40% 50% 5 The allowed 66 choosing your health plan

71 Abortion services 13 40% 50% Family Planning s Injectable and implantable contraceptives 3 Counseling and consulting 3 Tubal ligation 3 Vasectomy 40% Infertility services Rehabilitation and Habilitation s Office location 40% 50% Outpatient department of a hospital 40% 50% 5 The allowed Chiropractic s Chiropractic services Acupuncture s Acupuncture services 40% 50% Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Deductible for Pediatric Dental Coverage Child Dental Diagnostic and Preventive Oral exam No charge No charge 20% Preventive - cleaning No charge No charge 20% Preventive - X-ray No charge No charge 20% Sealants per tooth No charge No charge 20% Topical fluoride application No charge No charge 20% Caries risk management No charge No charge 20% Space maintainers - fixed No charge No charge 20% Child Dental Basic Services Amalgam fill - 1 surface No charge 20% 30% Child Dental Major Services 2 Root canal - molar No charge 50% 50% Gingivectomy per quad No charge 50% 50% Extraction - single tooth exposed root or No charge 50% 50% Extraction - complete bony No charge 50% 50% Porcelain with metal crown No charge 50% 50% Child Orthodontics 2 Medically necessary orthodontics No charge 50% 50% Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 14 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exam (92002/92004) 3 Covered up to a allowance of $ Covered up to a choosing your health plan 67

72 - Established patient exam (92012/92014) allowance of $30 3 Eyeglasses Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. 3 Covered up to a allowance of: $25 single vision 3 $35 lined bifocal 3 $45 lined trifocal 3 $45 lenticular 3 Optional Lenses and Treatments UV coating (standard only) 3 Anti-reflective coating (standard only) $35 3 High-index lenses $30 3 Photochromic lenses (glass or plastic) $25 3 Polarized lenses $45 3 Standard progressives $55 3 Premium progressives $95 3 Frame (one frame per calendar year) Collection frame Non-collection frame 15 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 16 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary 3 Covered up to a allowance of $ to 6 months) 3 3 to 3 months) 3 Covered up to a allowance $40 3 Covered up to a allowance of $75 3 Covered up to a allowance of $75 3 Covered up to a allowance of $75 3 Covered up to a allowance of $75 3 Covered up to a allowance of $225 for medically necessary contact lenses 3 Other Pediatric Vision s Supplemental low-vision testing and equipment 17 35% 3 Diabetes management referral 3 Please Note: s are subject to modification for subsequently enacted state or federal legislation. Pediatric Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 68 choosing your health plan

73 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. Endnotes for Bronze 60 HSA PPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 Members enrolled in this plan can access benefits from any provider, including a Blue Shield participating provider, a nonparticipating provider, or a provider for s; however, there is no member cost-sharing for services received from a provider or pharmacy for s. s from a provider or pharmacy for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 After the calendar year medical deductible is met, the member is responsible for a copayment or coinsurance from participating providers. providers accept Blue Shield s allowable amounts as full payment for covered services. Non-participating providers can charge more than these amounts. The member is responsible for these charges in addition to the applicable copayment or coinsurance when accessing these providers, which amount can be substantial. Amounts applied to the calendar year deductible accrue towards the applicable out-of-pocket. Charges in excess of the allowable amount do not count toward the calendar year medical deductible or out-of-pocket. 3 The covered services listed below are not subject to, and will not accrue to the calendar year medical deductible. Durable medical equipment: breast pump Family planning benefits: counseling and consulting; diaphragm fitting procedure; implantable contraceptives; injectable contraceptives; insertion and/or removal of IUD device; IUD; and tubal ligation Outpatient prescription drug benefits: contraceptive drugs and devices Pediatric vision benefits Pregnancy and maternity care benefits: prenatal and preconception physician office visits Preventive health services Pediatric dental benefits 4 Copayments or coinsurance for covered services apply toward the calendar year out-of-pocket, except copayments or coinsurance for the following (a) charges in excess of specified benefit s; (b) covered travel expenses for bariatric surgery; and (c) dialysis center services from a non-participating provider. Copayments, coinsurance, and charges for services not accruing to the calendar year out-of-pocket continue to be the member s responsibility after the calendar year out-of-pocket is reached. 5 The allowable amount for non-emergency services and supplies received from a non-participating hospital or facility is limited to for the coinsurance and all charges that exceed 6 The allowable amount for non-emergency services and supplies received from an ambulatory surgery center is limited to $300 per day. for the coinsurance and all charges that exceed $300 per day. ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 7 The allowable amount for non-emergency services and supplies received from a non-participating radiology center is limited to $300 per day. for all charges that exceed $300 per day. The allowable amount for non-emergency services and supplies received from a non-participating hospital is limited to for all charges that exceed 8 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage and Summary of s for details. choosing your health plan 69

74 9 This plan s prescription drug coverage provides less coverage on average than the standard benefit set by the federal government for Medicare Part D (also called non-creditable coverage). It is important to know that generally you may only enroll in a Medicare Part D plan from October 15th through December 7th of each year. If you do not enroll in a Medicare Part D plan when you are first eligible to join, you may be subject to a late enrollment penalty in addition to your Part D premium when you enroll at a later date. For more information about your current plan s prescription drug coverage, call the Customer Service telephone number on your identification card, Monday through Thursday between 8:00 a.m. and 5:00 p.m. or on Friday between 9:00 a.m. and 5:00 p.m. The hearing impaired may call the TTY number at (888) Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment and will not be subject to any calendar year medical deductible; however, if a brand contraceptive drug is requested when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year medical deductible or outof-pocket responsibility. 11 If a member or physician requests a brand drug when a generic drug equivalent is available, and the calendar year medical deductible has been satisfied, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost that the member must pay does not accrue to any calendar year medical deductible or out-of-pocket responsibility. Refer to the Evidence of Coverage and Summary of s for details. 12 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for acute medical detoxification, through a separate network of MHSA participating providers. Inpatient acute medical detoxification is a medical benefit provided by Blue Shield participating or non-participating (not MHSA) providers. 13 Copayment shown is for physician s services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 14 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 15 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 16 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 17 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required. This plan is pending regulatory approval. 70 choosing your health plan

75 Bronze 60 HSA EPO AI-AN (HSA-Compatible) This plan is only available to eligible s* Uniform Health Plan s and Coverage Matrix Blue Shield of California Effective January 1, 2015 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This HSA-eligible EPO plan uses the EPO provider network. This exclusive provider organization (EPO) plan utilizes a network of Providers. Except for Emergency Services, Urgent Services, or when prior authorized by Blue Shield, all services must be obtained from Providers to be covered. Calendar Year Medical Deductible 3 (Services received from providers are not subject to a deductible. Services received from participating providers are subject to a deductible. For family coverage, there is no individual deductible. Enrolled family members receive benefits for covered services once the family deductible has been satisfied by one, or any combination of family members. Medical deductible applies to all benefits except those in endnote 3.) Calendar Year Out-of-Pocket Maximum 4 (Services received from providers are not subject to a calendar year out-of-pocket. Services received from participating providers are subject to a calendar year out-of-pocket. The calendar year out-of-pocket includes the calendar year medical deductible.) $4,500 for individuals / $9,000 for families $6,250 for individuals / $12,500 for families Calendar Year Brand Drug Deductible (Brand drugs received from pharmacies are not subject to the calendar year brand drug deductible. Brand drugs received from a Blue Shield participating pharmacy are subject to the calendar year medical deductible.) Lifetime Maximum None Covered Services PROFESSIONAL SERVICES Professional (Physician) s Physician office visits from internal medicine, family practice, pediatric, and OB/Gyn physicians 40% Specialist physician office visits 40% Outpatient diagnostic X-ray and imaging 40% (non-hospital-based or -affiliated) Outpatient diagnostic laboratory and pathology (non-hospital-based or -affiliated) Preventive Health s Preventive health services (as required by federal and California law) 40% 3 OUTPATIENT SERVICES Outpatient surgery in a hospital 40% Outpatient surgery performed at an ambulatory 40% surgery center 5 Outpatient services for treatment of illness or injury 40% and necessary supplies Outpatient diagnostic X-ray and imaging performed in a hospital 40% choosing your health plan 71

76 Outpatient diagnostic laboratory and pathology 40% performed in a hospital CT scans, MRIs, MRAs, PET scans, and cardiac 40% diagnostic procedures utilizing nuclear medicine (prior authorization is required) HOSPITALIZATION SERVICES Inpatient physician services 40% Inpatient non-emergency facility services 40% (semi-private room and board, services and supplies, including subacute care) Bariatric surgery (prior authorization is required; medically 40% necessary surgery for weight loss is for morbid obesity only) 6 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission 40% 40% Emergency room services resulting in admission 40% 40% (when the member is admitted directly from the ER) Emergency room physician services 40% 40% Urgent care 40% 40% AMBULANCE SERVICES Emergency or authorized transport (ground or air) 40% 40% PRESCRIPTION DRUG COVERAGE 7,8,9 Pharmacy Pharmacy Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 3,8 Generic drugs 40% per prescription Preferred brand drugs 40% per prescription Non-preferred brand drugs 40% per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 3,8 Generic drugs 40% per prescription Preferred brand drugs 40% per prescription Non-preferred brand drugs 40% per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) 40% Oral Anti-cancer Medications 40% up to a of $200 per prescription PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copay may apply) Orthotic equipment and devices (separate office visit copay may apply) 40% 40% DURABLE MEDICAL EQUIPMENT Breast pump 3 Other durable medical equipment 40% MENTAL HEALTH SERVICES 10 Inpatient hospital services (prior authorization required) 40% Outpatient mental health services (some services may require prior authorization and facility charges) 40% SUBSTANCE ABUSE SERVICES 10 Inpatient hospital services (prior authorization required) 40% 72 choosing your health plan

77 Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 prior authorized visits per calendar year) 40% 40% OTHER Pregnancy and Maternity Care s Prenatal physician office visits 3 Postnatal physician office visits 40% Inpatient hospital services for normal delivery and 40% cesarean section Abortion services 11 40% Family Planning s Injectable and implantable contraceptives 3 Counseling and consulting 3 Tubal ligation 3 Vasectomy 40% Infertility services Rehabilitation and Habilitation s Office location 40% Outpatient department of a hospital 40% Chiropractic s Chiropractic services Acupuncture s Acupuncture services 40% Care Outside of California (benefits provided through the BlueCard Program for out-of-state emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable See Applicable See Applicable Outside of US: BlueCard Worldwide See Applicable See Applicable See Applicable Pediatric Dental s pediatric dental benefits are available for members through the end of the year in which the member turns 19 Deductible for Pediatric Dental Coverage Child Dental Diagnostic and Preventive Oral exam No charge No charge Preventive - cleaning No charge No charge Preventive - X-ray No charge No charge Sealants per tooth No charge No charge Topical fluoride application No charge No charge Caries risk management No charge No charge Space maintainers fixed No charge No charge Child Dental Basic Services Amalgam fill - 1 surface No charge 20% Child Dental Major Services 2 Root canal - molar No charge 50% Gingivectomy per quad No charge 50% Extraction - single tooth exposed root or No charge 50% Extraction - complete bony No charge 50% Porcelain with metal crown No charge 50% Child Orthodontics 2 Medically necessary orthodontics No charge 50% Pediatric Vision s for children up to age 19 Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) 3 Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) choosing your health plan 73

78 Optometric - New patient exam (92002/92004) - Established patient exam (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V ) - Conventional (lined) bifocal (V ) - Conventional (lined) trifocal (V ) - Lenticular (V2121, V2221, V2321) 3 3 Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Polycarbonate lenses are covered in full for eligible members. Optional Lenses and Treatments UV coating (standard only) 3 Anti-reflective coating (standard only) $35 3 High-index lenses $30 3 Photochromic lenses (glass or plastic) $25 3 Polarized lenses $45 3 Standard progressives $55 3 Premium progressives $95 3 Frame (one frame per calendar year) Collection frame Non-collection frame 13 Note: Collection frames are available at no cost at participating independent providers. Retail chain providers typically do not display the Collection, but are required to maintain a comparable selection of frames that are covered in full. Contact Lenses 14 Elective standard hard (V2500, V2510) Elective standard soft (V2520) to 6 months) Elective non-standard hard (V2501, V2502, V2503, V2511, V2512, V2513, V2599) Elective non-standard soft (V2521, V2512, V2523) to 3 months) Medically necessary 3 Covered up to a allowance of $ to 6 months) 3 3 to 3 months) 3 Other Pediatric Vision s Supplemental low-vision testing and equipment 15 35% 3 Diabetes management referral 3 Please Note: s are subject to modification for subsequently enacted state or federal legislation. Pediatric Dental s Endnotes: 1 The Calendar Year Deductible and Copayments for Covered Services from Dentists accrue to the Calendar Year Outof-Pocket Maximum, including any Copayments for covered orthodontia services received from Dentists. Costs for non- Covered Services, services from Dentists, charges in excess of benefit s, and Premiums, do not accrue to the Calendar Year Out-of-Pocket Maximum. The out-of-pocket for the embedded pediatric dental benefit accumulates to the overall combined medical and dental out-of-pocket amount. This is calculated as follows: (Federal out-ofpocket ) minus (SADP or Family Dental Plan out-of-pocket ) equals (QHP out-of-pocket ); numerically this is $6,600 - $350 = $6, There are no waiting periods for major & orthodontic services. 3 Medically necessary orthodontia services include an oral evaluation and diagnostic casts. An initial orthodontic examination (a Limited Oral Evaluation) must be conducted which includes completion of the Handicapping Labio-Lingual Deviation (HLD) Score sheet. The HLD Score Sheet is the preliminary measurement tool used in determining if the Member qualifies for medically necessary orthodontic services (see list of qualifying conditions below). Diagnostic casts may be covered only if qualifying conditions are present. Pre-certification for all orthodontia evaluation and services is required. Those immediate qualifying conditions are: Cleft lip and or palate deformities 74 choosing your health plan

79 Craniofacial Anomalies including the following: Crouzon s syndrome, Treacher-Collins syndrome, Pierre-Robin syndrome, Hemi-facial atrophy, Hem-facial hypertrophy and other severe craniofacial deformities which result in a physically handicapping malocclusion as determined by our dental consultants. Deep impinging overbite, where the lower incisors are destroying the soft tissue of the palate and tissue laceration and/or clinical attachment loss are present. (Contact only does not constitute deep impinging overbite). Crossbite of individual anterior teeth when clinical attachment loss and recession of the gingival margin are present (e.g., stripping of the labial gingival tissue on the lower incisors). Treatment of bi-lateral posterior crossbite is not a benefit of the program. Severe traumatic deviation must be justified by attaching a description of the condition. Overjet greater than 9mm or mandibular protusion (reverse overjet) greater than 3.5mm. The remaining conditions must score 26 or more to qualify (based on the HDL Index). 4 For Covered Services rendered by Dentists, the Member is responsible for all charges above the Allowable Amount. Endnotes for Bronze 60 HSA EPO AI-AN * means any individual as defined in section 4(d) of the Indian Self-Determination and Education Assistance Act (Pub. L ). Eligibility for coverage as a is determined by Covered California. 1 There is no member cost-sharing for services received from a provider or pharmacy for s. s from a provider or pharmacy for s refers to those essential health benefits furnished directly by the Indian Health Service (IHS), an Indian Tribe, a Tribal Organization, or an Urban Indian Organization or through referral under contracted health services (each as defined in 25 U.S.C. 1603). 2 After the calendar year medical deductible is met, the member is responsible for a copayment or coinsurance from participating providers. providers accept Blue Shield s allowable amounts as full payment for covered services. There is no nonemergency coverage for non-participating providers under the plan. for the full amount charged by nonparticipating providers. 3 The covered services listed below are not subject to, and will not accrue to the calendar year medical deductible. Durable medical equipment: breast pump Family planning benefits: counseling and consulting; diaphragm fitting procedure; implantable contraceptives; injectable contraceptives; insertion and/or removal of IUD device; IUD; and tubal ligation Outpatient prescription drug benefits: contraceptive drugs and devices Pediatric vision benefits Pregnancy and maternity care benefits: prenatal and preconception physician office visits Preventive health services Pediatric dental benefits 4 Copayments or coinsurance for covered services apply toward the calendar year out-of-pocket, except copayments or coinsurance for the following: (a) charges in excess of specified benefit s; and (b) covered travel expenses for bariatric surgery. Copayments, coinsurance, and charges for services not accruing to the calendar year out-of-pocket continue to be the member s responsibility after the calendar year out-of-pocket is reached. 5 ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 6 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties ( Designated Counties ), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage and Summary of s for details. 7 This plan s prescription drug coverage provides less coverage on average than the standard benefit set by the federal government for Medicare Part D (also called non-creditable coverage). It is important to know that generally you may only enroll in a Medicare Part D plan from October 15th through December 7th of each year. If you do not enroll in a Medicare Part D plan when you are first eligible to join, you may be subject to a late enrollment penalty in addition to your Part D premium when you enroll at a later date. For more information about your current plan s prescription drug coverage, call the Customer Service telephone number on your identification card, Monday through Thursday between 8:00 a.m. and 5:00 p.m. or on Friday between 9:00 a.m. and 5:00 p.m. The hearing impaired may call the TTY number at (888) Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment and will not be subject to any calendar year medical deductible; however, if a brand contraceptive drug is requested when a generic drug equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive drug and its generic drug equivalent. If the brand contraceptive drug is medically necessary, it may be covered without a copayment with prior authorization. The difference in cost that the member must pay does not accrue to any calendar year medical deductible or outof-pocket responsibility. 9 If a member or physician requests a brand drug when a generic drug equivalent is available, and the calendar year medical deductible has been satisfied, the member is responsible for paying the difference between the cost to Blue Shield for the brand drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost that the member must pay does not accrue to any calendar year medical deductible or out-of-pocket responsibility. Refer to the Evidence of Coverage and Summary of s for details. 10 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for acute medical detoxification, through a separate network of MHSA participating providers. Inpatient acute medical detoxification is a medical benefit provided by Blue Shield participating or non-participating (not MHSA) providers. 11 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. choosing your health plan 75

80 12 The comprehensive examination benefit and allowance does not include fitting and evaluation fees for contact lenses. 13 This benefit covers Collection frames at no cost at participating independent and retail chain providers. retail chain providers typically do not display the frames as Collection, but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames, the allowable amount is up to $150; however, if (a) the participating provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the participating provider uses warehouse pricing, then the warehouse allowable amount will be up to $ providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this benefit, the member is responsible for the difference between the allowable amount and the provider s charge. 14 Contact lenses are covered in lieu of eyeglasses once per calendar year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required. This plan is pending regulatory approval. 76 choosing your health plan

81 50 Beale Street, San Francisco, CA phone (415) Covered California is a registered trademark of the state of California. Blue Shield and the Shield symbol are registered marks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans. Blue Shield of California is an independent member of the Blue Shield Association A16646-NA (1/15)