Blue Shield of California benefit plans for Individual & Family benefit plans effective January 1, 2014.

Blue Shield of California benefit plans for Individual & Family benefit plans effective January 1, 2014. Blue Shield Product available through Covered California Same Blue Shield product sold outside of Covered California Blue Shield Provider Network for the IFP Product Platinum Platinum Ultimate PPO Ultimate PPO Exclusive PPO Network* Ultimate PPO Native American Exclusive PPO Network* or Indian Health Service Ultimate EPO Ultimate EPO Exclusive EPO Network ** Ultimate EPO Native American Exclusive EPO Network** or Indian Health Service Gold Gold Preferred PPO Preferred PPO Exclusive PPO Network* Preferred PPO Native American Exclusive PPO Network* or Indian Health Service Preferred EPO Preferred EPO Exclusive EPO Network** Preferred EPO Native American Exclusive EPO Network** or Indian Health Service Silver Silver Enhanced PPO Enhanced PPO Exclusive PPO Network* Enhanced PPO Native American Exclusive PPO Network* or Indian Health Service Enhanced PPO 150 Subsidy Exclusive PPO Network* Enhanced PPO 200 Subsidy Exclusive PPO Network* Enhanced PPO 250 Subsidy Exclusive PPO Network* Enhance EPO Enhanced EPO Exclusive EPO Network** Enhanced EPO Native American Exclusive EPO Network** or Indian Health Service Blue Shield of California is an independent member of the Blue Shield Association Covered California is a registered trademark of the state of California Page 1 of 3 11-21-13 Provider Relations Communications

Silver, cont d. Enhanced EPO 150 Subsidy Exclusive EPO Network** Enhanced EPO 200 Subsidy Exclusive EPO Network** Enhanced EPO 250 Subsidy Exclusive EPO Network** Bronze Bronze Basic PPO Basic PPO Exclusive PPO Network* Basic PPO Native American Exclusive PPO Network* or Indian Health Service Basic PPO for HSA Basic PPO for HSA Exclusive PPO Network* Basic EPO Basic EPO Exclusive EPO Network** Basic EPO Native American Exclusive EPO Network** or Indian Health Service Basic EPO for HSA Basic EPO for HSA Exclusive EPO Network** Catastrophic Catastrophic Get Covered PPO Get Covered PPO Exclusive PPO Network* Get Covered EPO Get Covered EPO Exclusive EPO Network** Native American Native American PPO 300 Subsidy* Exclusive PPO Network* or Indian Health Service Native American EPO 300 Subsidy** Exclusive EPO Network** or Indian Health Service Blue Shield of California is an independent member of the Blue Shield Association Covered California is a registered trademark of the state of California Page 2 of 3 11-21-13 Provider Relations Communications

*PPO plans are available for purchase in the following California counties: Contra Costa, El Dorado, Fresno, Imperial, Inyo, Kern, Kings, Los Angeles, Madera, Mariposa, Merced, Mono, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Luis Obispo, San Mateo, Santa Barbara, Santa Clara, Stanislaus, Tulare, Ventura, Yolo. **EPO plans are available for purchase in the following California counties, with the exception of the zip codes areas listed as excluded. EPO plan 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, Tuolome. EPO plan excluded zip code areas: 00012, 00019, 00022, 00028, 00031, 00033, 00034, 00035, 00037, 00038, 00039, 00040, 00047, 00048, 00049, 00050, 00054, 00055, 00065, 94512, 94533, 94535, 94536, 94538, 94539, 94555, 94560, 94571, 94585, 94586, 94587, 94929, 94937, 94940, 94956, 95006, 95017, 95033, 95043, 95223, 95224, 95228, 95229, 95232, 95233, 95245, 95247, 95248, 95251, 95254, 95255, 95257, 95305, 95321, 95335, 95364, 95375, 95410, 95412, 95415, 95417, 95421, 95423, 95425, 95427, 95428, 95429, 95432, 95445, 95449, 95450, 95454, 95459, 95463, 95466, 95468, 95469, 95480, 95486, 95488, 95494, 95497, 95514, 95526, 95527, 95528, 95543, 95546, 95548, 95549, 95550, 95552, 95554, 95555, 95556, 95558, 95563, 95565, 95568, 95569, 95570, 95571, 95573, 95585, 95587, 95589, 95595, 95620, 95625, 95629, 95644, 95666, 95669, 95687, 95688, 95689, 95696, 95728, 95914, 95915, 95920, 95930, 95939, 95941, 95942, 95947, 95951, 95955, 95959, 95960, 95963, 95977, 95979, 95980, 95983, 95986, 95987, 96006, 96008, 96009, 96011, 96013, 96014, 96015, 96017, 96021, 96022, 96023, 96027, 96029, 96031, 96032, 96033, 96034, 96037, 96039, 96040, 96041, 96044, 96046, 96047, 96050, 96051, 96054, 96056, 96057, 96058, 96059, 96061, 96062, 96064, 96065, 96068, 96069, 96070, 96071, 96074, 96075, 96076, 96084, 96085, 96086, 96088, 96091, 96092, 96094, 96096, 96108, 96109, 96110, 96112, 96113, 96114, 96116, 96117, 96118, 96119, 96121, 96123, 96124, 96126, 96128, 96132, 96134, 96135, 96136, 96162. Blue Shield of California is an independent member of the Blue Shield Association Covered California is a registered trademark of the state of California Page 3 of 3 11-21-13 Provider Relations Communications

Member ID cards for Individual & Family Plan EPO coverage purchased through exchange 1 3 4 2 1. Covered California logo 2. Blue Shield of California product (plan) name 3. This new, different Blue Shield Member Services phone number is only for IFP members who purchase coverage through Covered California: (855) 836-9705. 4. Blue Shield s dedicated Provider Customer Service phone number remains the same: (800) 541-6652. 1 blueshieldca.com

Member ID cards for Individual & Family Plan PPO coverage purchased through exchange 1 3 4 2 1. Covered California logo 2. Blue Shield of California product (plan) name 3. This new, different Blue Shield Member Services phone number is only for IFP members who purchase coverage through Covered California: (855) 836-9705. 4. Blue Shield s dedicated Provider Customer Service phone number remains the same: (800) 541-6652. 1 blueshieldca.com

On Exchange Example Eligibility Verification via blueshieldca.com/provider

products mapped to metal levels * * * See the PPO Benefit Summary Guide for details *These cost share percentages are based on member level spending. However the actuarial values, or the percentage of total medical costs the plan ultimately covers for each plan are actually 94% for PPO 150 Subsidy, 87% for PPO 200 Subsidy and 73% for PPO 250 Subsidy. 15 blueshieldca.com

Where IFP PPO and IFP EPO products are sold IFP PPO Products IFP EPO Products* No IFP PPO or EPO products sold through Covered California in these areas. We offer the PPO products in 28 counties. We offer the EPO products in 26 counties* *See appendix for EPO product zip code exclusions. 18 blueshieldca.com