Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum $1,000 per individual / $2,000 per family Lifetime Benefit Maximum

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1 City of San José Custom HMO $25 Copay (Retirees with Medicare Only) Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2017 THIS M ATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMM ARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Highlights: A description of the prescription drug coverage is provided separately Calendar Year Medical Deductible Calendar Year Out-of-Pocket Maximum $1,000 per individual / $2,000 per family Lifetime Benefit Maximum None Covered Services OUTPATIENT PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits (note: a woman may self-refer to an OB/GYN or family practice physician in her personal physician's medical group or IPA for OB/GYN services) Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine) Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections Access+ Specialist SM Benefits 1 Office visit, examination or other consultation (self-referred office visits and consultations only) Preventive Health Benefits Preventive health services (as required by applicable Federal and California law) OUTPATIENT FACILITY SERVICES Outpatient surgery performed at a free-standing ambulatory surgery center Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center Outpatient services for treatment of illness or injury and necessary supplies (except as described under " Rehabilitation Benefits" and "Speech Therapy Benefits") Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine) HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medi call y necessar y services and supplies, including subacute care) Inpatient Skilled Nursing Benefits 2, 3 (combined maximum of up to 100 days per benefit period; prior authoriza tion is required; semi-private accommodations) Free-standing skilled nursing facility Skilled nursing unit of a hospital EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not apply if the member is direc tl y admitted to the hospital for inpatient services) Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport (ground or air) None $40 per visit $50 per surgery $100 per surgery $100 per admission $100 per visit $50 per transport An independent member of the Blue Shield Association

2 PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits A description of your outpatient prescription drug coverage is provided separately. If you do not have the separate drug summary that goes with this benefit summary, please contact your benefits administrator or call the Member Services number on your identificati on card. PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based on allowed charges) MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES 4, 5 Inpatient hospital services $100 per admission Residential care $100 per admission Inpatient physician services Routine outpatient mental health and substance use disorder services (includes professional/physician visits) Non-routine outpatient mental health and substance use disorder services (includes behavioral health treatment, el ectroconvulsive therap y, intensive outpatient programs, office-based opioid treatment, partial hospitalization programs, psychological testing and transcranial magnetic stimulation) HOME HEALTH SERVICES Home health care agency services 2 Coverage limited to 100 visits per member per calendar year. Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency HOSPICE PROGRAM BENEFITS Routine home care Inpatient respite care 24-hour continuous home care Short-term inpatient care for pain and symptom management PREGNANCY AND MATERNITY CARE BENEFITS Prenatal and postnatal physician office visits (when billed as part of global maternity fee including hospital inpatient delivery services) (*There is a $25 copayment for the Initial office visit.) Abortion services (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center) FAMILY PLANNING AND INFERTILITY BENEFITS Counseling and consulting (Includes insertion of IUD, as well as injectable and implantable contraceptives for women) Infertility services (member cost share is based upon allowed charges) (diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemi nation and GIFT) Tubal ligation 50% Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center) REHABILITATION AND HABILITATION BENEFITS (Physical, Occupational and Respiratory Therapy) Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility) SPEECH THERAPY BENEFITS Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility) DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for testing supplies see Outpatient Prescription Drug Benefits) Diabetes self-management training HEARING AID SERVICES Audiological examination Hearing aid and ancillary equipment (Plan payment up to $1,000 maximum per member every 36 months) URGENT CARE BENEFITS Urgent care services outside your personal physician service area within California Urgent care services outside of California (BlueCard Program) SilverSneakers Fitness (Basic gym access through SilverSneakers Fitness. Classes that are designed to help improve your strength, flexibility, balance and endurance.) OPTIONAL BENEFITS Optional dental, vision, hearing aid, infertility, chiropractic or acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately.

3 1 To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. 2 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the plan deductible has been met. 3 Inpatient skilled nursing services are limited to 100 preauthorized days during a benefit period except when received through a hospice program provided by a participating hospice agenc y. This 100 preauthorized day maximum on inpatient skilled nursing services is a combined maximum between skilled nursing services provided in a hospital unit and skilled nursing services provided in a skilled nursing facility (SNF). 4 Mental health and substance use disorder services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) - using MHSA participating providers. 5 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers. Plan designs may be modified to ensure compliance with state and Federal requirements. A16205 (1/17) M P This plan is pending regulatory approval.

4 City of San José (Retirees with Medicare Only) Chiropractic and Acupuncture Benefits Additional coverage for your HMO Plans Blue Shield Chiropractic and Acupuncture Care coverage lets you self-refer to a network of more than 4,000 licensed chiropractors and more than 2,500 licensed acupuncturists. Benefits are provided through a contract with American Specialty Health Plans of California, I nc. (ASH Plans). How the Program Works You can visit any participating chiropractors or acupuncturists in California from the ASH Plans network without a referral from your HMO Personal Physician. Simply call a participating provider to schedule an initial exam. At the time of your first visit, you ll present your Blue Shield identification card and pay only your copayment. Because participating chiropractors and acupuncturists bill ASH Plans directly, you ll never have to file claim forms. If you need further treatment, the participating chiropractor or acupuncturist will submit a proposed treatment plan to ASH Plans and obtain the necessary authorization from ASH Plans to continue treatment up to the calendar year maximum of 30 combined visits. What s Covered The plan covers medically necessary chiropractic and acupuncture services including: Initial and subsequent examinations Office visits and adjustments (subject to annual limits) Adjunctive therapies X-rays (chiropractic only) Benefit Plan Design Calendar year Maximum Calendar year Deductible 30 Combined Visits Calendar year Chiropractic Appliances Benefit 1,2 $50 Covered Services Acupuncture Services Chiropractic Services Out-of-network Coverage None Member Copayment $10 per visit $10 per visit 1. Chiropractic appliances are cov ered up to a maximu m of $50 in a calendar year as authorized by ASH Plans. 2. As authorized by ASH Plans, this allowance is applied toward the purchase of items determined necessary, such as supports, collars, pillows, heel lifts, ice packs, cushions, orthotics, rib belts and home traction units. None An independent member of the Blue Shield Association A17273 (01/17) MP082916

5 Friendly Customer Service Helpful ASH Plans Member Services representatives are available at (800) Monday through Friday from 6 a.m. to 5 p.m. to answer questions, assist with problems, or help locate a participating chiropractor or acupuncturist. This document is only a summary for informational purposes. It is not a contract. Please refer to the Evidence of Coverage and the Group Health Service Agreement for the exact terms and conditions of coverage. This plan is pending regulatory approval.

6 summary of benefits Blue Shield of California Medicare Rx Plan (PDP) An employee sponsored Medicare Prescription Drug Plan for City of San Jose retirees January 1, 2017 to December 31, 2017 S2468_16_169H CSJ-HMO

7 This booklet gives you a summary of what we cover and what you pay. It doesn t list every service that we cover or list every limitation or exclusion. To get a complete list of services we cover, call us and ask for the Evidence of Coverage. Blue Shield of California is a not-for-profit company that s been serving Californians for more than 75 years. Our mission is to ensure all Californians have access to high-quality health care at an affordable price. Blue Shield of California Medicare Rx Plan (PDP) Phone Numbers and Website If you are a member of this plan, call toll-free (888) [TTY: 711]. If you are not a member of this plan, call toll-free (888) [TTY: 711]. Our website: Hours of Operation From October 1 to February 14, you can call us 7 days a week from 8:00 a.m. to 8:00 p.m. Pacific time. From February 15 to September 30, you can call us Monday through Friday from 8:00 a.m. to 8:00 p.m. Pacific time. Who can join? To join Blue Shield of California Medicare Rx Plan (PDP), you must be entitled to Medicare Part A, and/or be enrolled in Medicare Part B, meet your former employer group/union s eligibility requirements, and live in the plan service area. Your Medicare-eligible spouse and dependents may also join Blue Shield of California Medicare Rx Plan (PDP) if they meet these requirements. Our service area includes the following: California. Which pharmacies can I use? We have a network of pharmacies and you must generally use these pharmacies to fill your prescriptions for covered Part D drugs. Some of our network pharmacies have preferred cost-sharing. You may pay less if you use these pharmacies. You can see our plan s pharmacy directory at our website ( Or, call us and we will send you a copy of the pharmacy directory. What drugs are covered? You can see the complete plan formulary (list of Part D prescription drugs) and any restrictions on our website ( Or, call us and we will send you a copy of the formulary. A-2

8 If you want to know more about the coverage and costs of Original Medicare, look in your current "Medicare & You" handbook. View it online at or get a copy by calling MEDICARE ( ), 24 hours a day, 7 days a week. TTY users should call PRESCRIPTION DRUG BENEFITS How much is Your former employer group/union is responsible for paying premiums the monthly beyond your monthly Medicare Part B premium. If you are responsible for premium? any contribution to the premiums, your benefits administrator will tell you the amount you and your former employer group/union contribute to the premium. In addition, you must keep paying your Medicare Part B premium. How much is the deductible? Initial Coverage This plan does not have a deductible. You pay the following until your total yearly out-of-pocket drug costs reach $4,950. You may get your drugs at network retail pharmacies and our mail service pharmacy. Standard Retail Cost-Sharing Tier One-month supply Three-month supply Tier 1 (Generic) $10 copay $30 copay Tier 2 (Preferred Brand) $25 copay $75 copay Tier 3 (Non-Preferred Brand) $40 copay $120 copay Tier 4 (Injectable Drugs) $40 copay $120 copay Tier 5 (Specialty Tier) $40 copay A long-term supply is not available for drugs in Tier 5. Preferred Retail Cost-Sharing or Standard Mail Order Cost-Sharing Tier Three-month supply Tier 1 (Generic) $20 copay Tier 2 (Preferred Brand) $50 copay Tier 3 (Non-Preferred Brand) $80 copay Tier 4 (Injectable Drugs) $120 copay A long-term supply is not Tier 5 (Specialty Tier) available for drugs in Tier 5. A-3

9 If you reside in a long-term care facility, you pay the same as at a standard retail cost-sharing pharmacy. You may get drugs from an out-of-network pharmacy at the same cost as an in-network standard retail cost-sharing pharmacy. Coverage Gap Because there is no coverage gap for the plan, this payment stage does not apply to you. Catastrophic Coverage After your yearly out-of-pocket drug costs (including drugs purchased through your retail pharmacy and through mail order) reach $4,950, you pay the lower of: 5% of the cost, or Your applicable drug tier cost-sharing amount. Blue Shield of California is a PDP plan with a Medicare contract. Enrollment in Blue Shield of California depends on contract renewal. This information is not a complete description of benefits. Contact the plan for more information. Limitations, copayments, and restrictions may apply. Benefits, premiums and/or copayments/coinsurance may change on January 1 of each year. The Formulary and pharmacy network may change at any time. You will receive notice when necessary. Blue Shield of California complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex. Blue Shield of California cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, color, nacionalidad, edad, discapacidad o sexo. Blue Shield of California 遵守適用的聯邦民權法律規定, 不因種族 膚色 民族血統 年齡 殘障或性別而歧視任何人 PDP00037-CityofSanJose-HMO (10/16) A-4 An independent member of the Blue Shield Association