go with ^ Blue Shield PPO plan with Health Savings Account Blue Shield EPO plan Effective January 1, 2015 HIGHLIGHTS Plan overview 1

Transcription

1 go with ^ Blue Shield PPO plan with Health Savings Account Blue Shield EPO plan Effective January 1, 2015 HIGHLIGHTS Plan overview 1 Pharmacy benefits 9 How to find a provider 10 Programs and services 12 Benefit summaries 14

2 Go with the plan that s right for you

3 When you go with Blue Shield of California, you re on your way to quality health coverage, large provider networks, and a wide range of programs and services that help provide the most value from your coverage. This booklet offers the information you need to choose the right health plan for you and your family. Plan choices During the 2015 annual enrollment period, SSL is offering the choice of the following Blue Shield health plans: Blue Shield PPO plan with Health Savings Account Blue Shield EPO plan To make it easier to compare the plans, we ve included a description of the unique features of each and a benefit comparison chart on page 7 of this booklet. You can also visit blueshieldca.com/ssl for additional benefit details.

4 Blue Shield PPO plan with Health Savings Account (HSA) The Blue Shield PPO is a high-deductible health plan that provides the freedom to select any physician and hospital inside or outside the plan s network. Please note: Your out-of-pocket costs will be lower by choosing a provider within your network. If your physician is not part of the Blue Shield network, you will have to pay more for each service. HOW THE PLAN WORKS When you see a network provider for covered services: PPO network providers will submit their claims to Blue Shield. You pay 100% of the allowed amount for services, except for preventive care, until you meet your calendar-year deductible. After you meet the calendar-year deductible amount, you pay a copayment or coinsurance for covered services. When you see a non-network provider for covered services: You pay 100% of the amount billed for covered services until you ve met your calendar-year deductible. Only the amount allowed by Blue Shield of California will apply to the deductible accumulation. After you meet the calendar-year deductible amount, you pay a copayment or coinsurance for covered services, which is based on Blue Shield s allowable amount, plus any charges above the allowable amount. The additional charges above the allowable amount can be substantial. Non-network providers will usually require you to pay 100% of the cost of the service. You will then need to submit a claim along with the itemized bill from your provider to Blue Shield. Estimate your medical costs Blue Shield s Treatment Cost Estimator tool provides PPO plan members with estimates of both the total cost and out-of-pocket expenses for common network medical treatments and services. These estimates provide the transparency and clarity to help you budget and plan for future healthcare expenses. 02 Blue Shield of California

5 Health savings account (HSA) This Blue Shield PPO plan includes a health savings account (HSA),* a federal tax-free savings account, administered by HealthEquity, and can be used to help you pay your deductible and qualified out-of-pocket medical expenses. You can also save it and let it grow from year to year. For the 2015 calendar year, the SSL will contribute the following amounts to your HSA: $500 credited to your HSA when you get an annual physical (plus your exam is free when you see a participating physician). $250 credited to your HSA when your enrolled spouse/ domestic partner or eldest dependent child (when no spouse or domestic partner is enrolled) gets an annual physical. Other advantages of the HSA include: You can keep the HSA, including all the money you contribute, even if you don t spend it, change jobs, retire, or leave the health plan. You never pay federal taxes on withdrawals for qualified medical expenses. Your money earns interest and you don t pay federal taxes on the interest earned. Once your HSA balance accrues more than $2,000, you can invest any amount in excess of the $2,000 into a mutual fund. For more information on the HSA, go to blueshieldca.com/ssl. You can also contribute pre-tax dollars from your paycheck. All contributions, including those provided by SSL, cannot exceed IRS guidelines. * Although most individuals who enroll in an HSA-compatible high-deductible health plan (HDHP) are eligible to open a health savings account (HSA), you should consult with a financial adviser to determine if the Health Savings Plan with HSA is a good financial fit for you. Blue Shield does not offer tax advice for HSAs, as HSAs are offered through financial institutions. The HSA is offered through HealthEquity, a company independent from Blue Shield of California. Blue Shield does not offer tax advice for HSAs since HSAs are offered through financial institutions. For more information about HSAs, eligibility, and the law s current provisions, please consult your financial or tax adviser. Currently, for residents of California, Alabama, and New Jersey, HSA contributions are not excluded from state income tax. For more information, please consult your tax adviser. Plan highlights Here are a few highlights of the services covered by the PPO plan. For details on copayment and coinsurance amounts, please see the benefit overview on page 7. To find network providers, see page 10. Preventive care Provides access to services defined as routine preventive care at no additional charge and without having to pay a copayment or meet the plan s deductible. You can download a list of recommended screenings and immunizations by going to blueshieldca.com/preventive. Specialty care You can access care through a specialist without a referral from your primary care physician. Mental health and substance abuse care You have access to inpatient and outpatient mental health and substance abuse care for issues such as depression, alcohol/drug abuse, mental illness, and marriage and family counseling through Blue Shield s mental health service administrator (MHSA) provider network, Blue Shield s PPO network, and non-network providers. Urgent care It s possible to save time and money by going to an urgent care center instead of the emergency room. To find an urgent care center, visit blueshieldca.com/ucc-ppo. Emergency care You re covered for emergency care around the world regardless of whether or not the provider is in your plan s PPO network. Chiropractic and acupuncture services Visit any participating chiropractor or acupuncturist from the American Specialty Health (ASH) Plans network without a referral from your primary care physician. Accessing care away from home Through the BlueCard Program, you have access to care across the United States and urgent and emergency care around the world. You can receive urgent care services from any provider; however, using a provider in the BlueCard Program can be more costeffective and may eliminate the need for you to pay for the services when they are rendered and the need to submit a claim for reimbursement. For complete information on covered services while traveling, please see your Evidence of Coverage and Disclosure (EOC&D). Go to blueshieldca.com/ssl 03

6 Exclusive Provider Organization (EPO) plan The Blue Shield Exclusive Provider Organization (EPO) plan is structurally similar to an HMO plan, except that you do not need to select a Personal Physician. If you seek care as an EPO member, you choose from physicians and hospitals in the preferred provider (PPO) network. Non-network services are not covered, except for urgent and emergency care. Choosing a Personal Physician This plan does not require you to choose a personal physician; however, you must choose from physicians and hospitals in the preferred provider network. 04 Blue Shield of California

7 Have questions? Get answers. Call the Blue Shield Member Services team at (855) Visit blueshieldca.com/ssl to find providers, review medical benefits, and more. Download the Blue Shield Mobile app for iphone or Android at blueshieldca.com/mobile. Connect with Team Shield on Facebook/BlueShieldCA or Twitter/TeamShieldBSC and post a question. HOW THE PLAN WORKS With the Blue Shield EPO plan, there are no deductibles or coinsurance, and you only need to pay a copayment for most covered services like doctor visits, prescription drugs, urgent care visits, and emergency care (just to name a few). You only have access to providers in the Blue Shield PPO network. Services provided by non-network providers, except for emergencies, are not covered by the plan. For some services, Blue Shield may require that you use a specific network provider. Plan highlights Here are a few highlights of the services covered by the EPO plan. For details on copayment amounts, please see the benefit overview on page 7. To find network providers, see page 10. Preventive care Provides access to services defined as routine preventive care at no additional charge and without having to pay a copayment or meet the plan s deductible. You can download a list of recommended screenings and immunizations by going to blueshieldca.com/preventive. Specialty care You can see any specialist in the PPO network when needed without prior authorization from your primary physician. However, some services may require prior authorization. Mental health and substance abuse care Blue Shield s mental health service administrator (MHSA) provider network offers access to inpatient and outpatient mental health and substance abuse care for depression, alcohol/drug abuse, mental illness, plus marriage and family counseling. Urgent care It s possible to save time and money by going to an urgent care center instead of the emergency room. To find a network urgent care center, visit blueshieldca.com/ucc-ppo. If you receive care at an urgent care center that s not in the Blue Shield PPO network, your plan may not cover the services you receive. Emergency care You re covered for emergency care around the world regardless of whether or not the provider is in your plan s PPO network. Chiropractic and acupuncture services Visit any participating chiropractor or acupuncturist from the American Specialty Health (ASH) Plans network without a referral from your primary care physician. Accessing care away from home Through the BlueCard Program, you have access to care across the United States and urgent and emergency care around the world. You can receive urgent care services from any provider; however, using a provider in the BlueCard Program can be more costeffective and may eliminate the need for you to pay for the services when they are rendered and submit a claim for reimbursement. For complete information on covered services while traveling, please see your Evidence of Coverage and Disclosure (EOC&D). Go to blueshieldca.com/ssl 05

8 Compare plan features Blue Shield EPO plan Blue Shield PPO Plan with Health Savings Account (HSA) NETWORK NON-NETWORK Out-of-pocket costs Pay a copayment for covered services. Pay a copayment or coinsurance for covered services. (Calendar-year deductible may apply.) After calendar-year deductible is met, pay a percentage of costs and all costs above the allowable amount. Choosing a doctor Visit any PPO network physician; no referral is required. You will not have coverage if you seek services from providers outside the network, except for emergencies. We require pre-authorization on certain procedures and treatments. For some services, we may require that you use a specific network provider. Visit any PPO network physician. Visit any PPO network specialist; no referral is required. Visit any non-network physician, pay for the services, and submit claims to Blue Shield. Visit any non-network specialist and submit claims to Blue Shield. No referral is required. Access to specialists Visit any PPO network specialist; no referral is required. Visit any PPO network specialist; no referral is required. Visit any non-network specialist and submit claims to Blue Shield. You will not have coverage if you seek services from providers outside the network, except for emergencies. We require pre-authorization on certain procedures and treatments. For some services, we may require that you use a specific network provider.* No referral is required. 06 Blue Shield of California

9 Compare plan benefits EPO plan Blue Shield PPO Plan with Health Savings Account (HSA) NETWORK NETWORK NON-NETWORK Plan-year deductible None $2.000 individual/ $4.000 family $3.000 individual/ $6,000 family Plan-year out-of-pocket maximum or copayment maximum $3.000 individual/ $6,000 family $5,000 individual/ $7,500 family $5,000 individual/ $7,500 family MEMBER COPAYMENT MEMBER COPAYMENT/COINSURANCE (ONCE PLAN DEDUCTIBLE IS MET) Physician office visit $30 per visit 20% 40% Specialist office visit $30 per visit 20% 40% Preventive health benefits No charge No charge (not subject to plan deductible) 40% Outpatient surgery in hospital Inpatient facility services (non-emergency) $250 per surgery 20% 40% $200 per day 20% 40% Urgent care center visit $30 per visit 20% 40% (once plan deductible is met) Emergency room services (not resulting in admission) $150 per visit 20% 20% Substance abuse (inpatient/outpatient physician visit) $200 per day (Inpatient) $30 per visit (Outpatient) 20% 40% Pregnancy and maternity care benefits No charge 20% 40% Acupuncture benefits $30 (up to 30 visits per plan-year, combined with chiropractic) 20% (up to 60 visits per plan-year, combined with chiropractic) 40% (up to 60 visits per plan-year, combined with chiropractic) Chiropractic benefits (provided by a chiropractor) $30 (up to 30 visits per plan-year, combined with acupuncture) 20% (up to 60 visits per plan-year, combined with acupuncture) 40% (up to 60 visits per plan-year, combined with acupuncture) Prenatal and postnatal physician office visits. For inpatient hospital services, see Hospitalization Services on the benefit summary in the back of this booklet. For urgent care services performed at a Freestanding Urgent Care Center, please refer to the Physician In-Office Visit/Consultation benefits. For urgent care services performed at a center affiliated with a licensed hospital please refer to Emergency Room Benefits. Go to blueshieldca.com/ssl 07

10 Pharmacy benefits We want you to get the most from the pharmacy benefits in your Blue Shield health plan. Below is helpful information to get started with your pharmacy benefits. To learn more, go to blueshieldca.com and visit our site s Pharmacy section. You ll discover helpful services, tools, and programs including: Pharmacy Tools Our new Pharmacy Tools section offers easy, quick, and secure access to: up to 24 months of pharmacy claims information, plan-specific drug pricing, pharmacy locations, drug condition and interaction information, and more. To access these tools, you will need to log in to blueshieldca.com. Plus Drug Formulary If you re currently taking a medication, check the Blue Shield Drug Formulary to see if your medication is in our list of preferred prescription drugs. If you don t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team for personal assistance or to request a copy of our formulary. Prescriptions by mail If you take stabilized doses of covered long-term maintenance medications for conditions such as diabetes, you are required to use the mail-order service. It s easy to order a mailservice refill of up to a 90-day supply. You may also save money on your copayment and there is no charge for shipping. Ask the pharmacist As a member, simply submit your question to pharmacists at the University of California, San Francisco, and receive a confidential answer online within two days. Or browse the top questions and search an archive of answers. To use this feature, you will need to log in to blueshieldca.com. If you have any questions, simply contact your Blue Shield Member Services team at (855) for personal assistance from 7 a.m. to 7 p.m., Monday through Friday. Compare prescription drug cost Members can compare the costs of generic versus brand-name drugs and compare the costs of drugs at up to five network pharmacies. Just log in to blueshieldca.com, select Pharmacy Tools, then Drug Pricing Tool. 08 Blue Shield of California

11 Compare pharmacy benefits To learn more about these plans, please see the benefit summaries that begin on page 14. Blue Shield EPO plan Blue Shield PPO plan with HSA PARTICIPATING PHARMACY PARTICIPATING PHARMACY NON-PARTICIPATING PHARMACY Annual deductible None Subject to medical deductible Subject to medical deductible MEMBER COPAYMENT MEMBER COPAYMENT (ONCE PLAN DEDUCTIBLE IS MET) Retail prescriptions (for up to a 30-day supply) Contraceptive drugs and devices No charge No charge Not covered Formulary generic drugs $15 per prescription 20% Not covered Formulary brand-name drugs $30 per prescription 20% Not covered Non-formulary brand-name drugs $50 per prescription 20% Not covered Mail-service prescriptions (for up to a 90-day supply) Contraceptive drugs and devices No charge No charge Not covered Formulary generic drugs $30 per prescription 20% Not covered Formulary brand-name drugs $75 per prescription 20% Not covered Non-formulary brand-name drugs $150 per prescription 20% Not covered Go to blueshieldca.com/ssl 09

12 Find a network provider Blue Shield s networks are some of the largest in California. The PPO network includes more than 70,000 physicians and 350 hospitals. Search for a network provider in California PPO network providers It s fast and easy to find a network provider online: For PPO providers, go to blueshieldca.com/networkppo. Then, select the type of provider that you are searching for. Click on Advanced Search to further filter your search, such as by name, specialty, facility type, and more. Enter your city and state or ZIP code, then click Find now. Get results as a PDF Create a PDF of your search results: Follow the steps to find a network provider in the previous paragraph and select Get results as PDF in the upper right corner of the screen. Then follow the instructions to download or have the listing ed to you in a PDF format. Create a PDF directory by county or ZIP code: Go to blueshieldca.com/networkppo and select Directory Online (on the left side of the page) and follow the instructions. 10 Blue Shield of California

13 If you don t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team at (855) for personal assistance or to request a provider directory. If you have any questions, contact your Blue Shield Member Services. Search for a network provider outside of California Within the United States Go to provider.bcbs.com. Enter the first three letters of your member ID or leave blank if you aren t a member. Search by Keyword or by Specialty. Enter a location and a radius to search by (default is 5 miles). Click on Go. Find out your provider s quality of care rankings You can easily access quality scores, efficiency indicators, patient satisfaction scores, and cost information for many individual physicians, HMO medical groups, and hospitals. To see a provider s performance profile, follow the steps above to find a provider and then click on the name of the doctor or hospital from your search results. Outside of the United States Go to bluecardworldwide.com. Accept the terms and conditions. Enter the first three letters of your member ID or leave blank if you aren t a member. Click Login. Go to blueshieldca.com/ssl 11

14 Going with Blue Shield means added programs and services Condition management programs These programs offer nurse support as well as education and self-management tools for members with asthma, diabetes, coronary artery disease, heart failure, and chronic obstructive pulmonary disease. Teladoc Teladoc provides 24/7/365 access to a network of board-certified doctors who can treat many of your medical issues, anytime, through the convenience of phone and online video consultations. The cost is $10 per consultation for EPO participants and $40 per consultation for PPO participants. If you are a PPO participant, you will be responsible for 100% of the cost until your deductible is met. Once you have met your annual medical deductible, you will be reimbursed 80% of the cost by Blue Shield. Your final copay will be $8. To learn more go to com/bsc or call Teladoc at Teladoc ( ). Prenatal Program This program gives expectant parents access to prenatal and child-rearing information including a popular pregnancy or parenting book at no additional cost. Wellvolution We know we could be healthier, but life is busy and things get in the way. Wellvolution SM is an easy, social, and fun approach to wellness. Participate on the go, from your computer, smartphone, or tablet, and invite your family and friends to join the fun and support your health goals. Just go to for access to: Well-Being Assessment Take our quick and confidential Well-Being Assessment and receive a personalized report of your overall well-being and suggestions on ways to improve your health. Daily Challenge Every day you ll get an to perform one simple wellness-related task that s fun to do. Earn points, and connect with your friends and family as you explore activities to improve many areas of your well-being. 12 Blue Shield of California

15 Have questions? Get answers. Call the Blue Shield Member Services team at (855) Visit blueshieldca.com/ssl to find providers, review medical benefits, and more. Download the Blue Shield Mobile app for iphone or Android at blueshieldca.com/mobile. Connect with Team Shield on Facebook/BlueShieldCA or Twitter/TeamShieldBSC and post a question. Wellness discount programs Blue Shield offers a variety of member discounts on popular weight loss, fitness, vision, and health and wellness programs 1 that can help you save money and get healthier. Weight Watchers Get discounts on three- and 12-month subscriptions, monthly passes, and at-home kits. 24 Hour Fitness Enjoy waived enrollment, processing, and initiation fees and discounts on monthly membership dues. ClubSport and Renaissance ClubSport Obtain a 60% discount on enrollments when joining with a month-to-month agreement. Enrollment fees are waived when joining with a 12-month agreement. (There is a one-time $25 processing fee when you enroll.) Alternative Care Discount Program Get 25% off usual and customary fees for acupuncture, chiropractic services, and massage therapy, plus get discounts on health and wellness products, with free shipping on most items. Discount Provider Network 2 Take 20% off the published retail prices when you use a participating provider in the Discount Vision Program network for exams, frames, lenses, and more. MESVision Optics Take advantage of competitive prices on contact lenses, 3 sunglasses, readers, and eyecare accessories, with free shipping on orders over $50. Blue Shield vision plan members can apply their benefits to reduce their out-of-pocket costs for contact lenses. QualSight LASIK Save on LASIK surgery at more than 45 surgery centers in California. Services include pre-screening, a pre-operative exam, and post-operative visits. NVISION Laser Eye Centers Receive a 15% discount on LASIK surgery from experienced surgeons with offices in Southern California and Sacramento. Daily Challenge is a registered trademark of MeYouHealth. MeYouHealth is a wholly owned subsidiary of Healthways, Inc. Wellvolution is a service mark of Blue Shield 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. Please refer to the endnotes on inside back cover for all pertinent wellness discount program notations. Go to blueshieldca.com/ssl 13

16 Review benefit summaries ASO PPO Health Savings Account Plan Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Effective: January 1, 2015 Calendar Year Medical Deductible (For family coverage, the full family deductible must be met before the enrollee or covered dependents can receive benefits for covered services) (Copayments/Coinsurance for Preferred Providers accrues to both Preferred and Non- Preferred Provider Calendar-year Deductible amounts.) Calendar Year Copayment Maximum (Includes the plan deductible) (For family coverage, the full family out-of-pocket must be met before the enrollee or covered dependents can receive 100% benefits for covered services.) (Copayments/Coinsurance for Preferred Providers accrues to both Preferred and Non- Preferred Provider Calendar-year Copayment Maximum amounts.) Preferred Providers 1 Non-Preferred Providers 1 $2,000 per individual / $4,000 per family $5,000 per individual / $7,500 per family $3,000 per individual / $6,000 per family $5,000 per individual / $7,500 per family LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Preferred Providers 1 Non-Preferred Providers 1 Professional (Physician) Benefits Physician and specialist office visits 20% 40% Teladoc physician consultation 20% Not Covered CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required) 3 20% 40% Other outpatient X-ray, pathology and laboratory (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities) 3 20% 40% Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 20% 40% Preventive Health Benefits Preventive Health Services (As required by applicable federal law.) No Charge (Not subject to the Calendar-Year Deductible) OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery Center 4 20% 40% Outpatient surgery in a hospital 20% 40% Outpatient Services for treatment of illness or injury and necessary 20% 40% supplies (Except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic 20% 40% procedures utilizing nuclear medicine performed in a hospital (prior authorization is required) 3 Other outpatient X-ray, pathology and laboratory performed in a 20% 40% hospital 3 Bariatric Surgery Not Covered Not Covered HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient Physician Services 20% 40% Inpatient Non-emergency Facility Services (Semi-private room and board, 20% 40% and medically-necessary Services and supplies, including Subacute Care) Bariatric Surgery Not Covered Not Covered 40% An Independent Licensee of the Blue Shield Association 14 Blue Shield of California

17 Skilled Nursing Facility Benefits 5 (Combined maximum of up to 60 prior authorized days per Calendar Year; semi-private accommodations) Services by a free-standing Skilled Nursing Facility 20% 40% 9 Skilled Nursing Unit of a Hospital 20% 40% EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission (The ER copayment 20% 20% does not apply if the member is directly admitted to the hospital for inpatient services) Emergency room Services resulting in admission (when the member is 20% 20% admitted directly from the ER) Emergency room Physician Services 20% 20% AMBULANCE SERVICES Emergency or authorized transport 20% 20% 11, 12, 13, 14, 15, 16, 17 PRESCRIPTION DRUG COVERAGE (Subject to deductible; includes covered diabetic drugs and testing supplies) Participating Pharmacy Non-Participating Pharmacy Outpatient Prescription Drug Benefits Retail Prescriptions (For up to a 30-day supply) Value-Based Tier Drugs 2 No Charge Not Covered Contraceptive Drugs and Devices 17 No Charge Not Covered Formulary Generic Drugs 20% per prescription Not Covered Formulary Brand Name Drugs 20% per prescription Not Covered Non-Formulary Brand Name Drugs 20% per prescription Not Covered Mail Service Prescriptions (For up to a 90-day supply) Value-Based Tier Drugs 2 No Charge Not Covered Contraceptive Drugs and Devices 17 No Charge Not Covered Formulary Generic Drugs 20% per prescription Not Covered Formulary Brand Name Drugs 20% per prescription Not Covered Non-Formulary Brand Name Drugs 20% per prescription Not Covered Specialty Pharmacies (up to a 30-day supply) Specialty Drugs Applicable Drug Tier Copayment Applies Not Covered PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (Separate office visit copay may apply) 20% 40% Orthotic equipment and devices (Separate office visit copay may apply) 20% 40% DURABLE MEDICAL EQUIPMENT Breast pump No Charge 40% (Not subject to the Calendar-Year Deductible) Durable Medical Equipment 20% 40% MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 7, 8 Inpatient Hospital Services 20% 40% Residential Care 20% 40% Outpatient Mental Health and Substance Services 20% 40% HOME HEALTH SERVICES 9 Home health care agency Services (up to 120 prior authorized visits per 20% 40% 9 Calendar Year) 5 Home infusion/home intravenous injectable therapy and infusion nursing visits provided by a Home Infusion Agency 20% 40% 9 OTHER Hospice Program Benefits Routine home care 20% 40% 9 Inpatient Respite Care 20% 40% 9 24-hour Continuous Home Care 20% 40% 9 General Inpatient care 20% 40% 9 Chiropractic Benefits 5 Chiropractic Services (Up to 60 visits per Calendar Year combined with Acupuncture services) Acupuncture Benefits Acupuncture (Up to 60 visits per Calendar Year combined with Chiropractic services) Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) 5 Office location (Up to 60 visits per Calendar Year for physical and occupational therapy combined with speech therapy benefits) 20% 40% 20% 40% 20% 40% Go to blueshieldca.com/ssl 15

18 Speech Therapy Benefits 5 Office Visit - Services by licensed speech therapists (Up to 60 visits per Calendar Year combined with physical and occupational therapy.) Pregnancy and Maternity Care Benefits Prenatal and postnatal Physician office visits (For inpatient hospital services, see "Hospitalization Services.") ASO (1/14) JT % 40% 20% 40% Abortion services 6 20% 40% Family Planning Benefits Counseling and consulting 10 No Charge (Not subject to the Calendar-Year Deductible) 40% Tubal ligation No Charge 40% (Not subject to the Calendar-Year Deductible) Vasectomy 6 20% 40% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see Outpatient Prescription Drug Benefits.) 20% 40% Diabetes self-management training 20% 40% Care Outside of Plan Service Area (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 Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit 1 Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. Preferred providers agree to accept Blue Shield's allowable amount plus the plan s and any applicable member s payment as full payment for covered Services. Non-preferred providers can charge more than these amounts. When members use non-preferred providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the Calendar Year deductible or copayment maximum. 2 Value-Based Tier Drugs are specific preventive generic and brand name drugs on the Blue Shield Formulary that are FDA-approved for hypertension, high cholesterol, diabetes and asthma. As preventive care, there is no copayment or coinsurance for Value-Based Tier Drugs and the benefit is not subject to the calendar-year medical deductible. 3 Participating non Hospital based ("freestanding") laboratory or radiology centers may not be available in all areas. Laboratory and radiology Services may also be obtained from a Hospital or from a laboratory and radiology center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 4 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 5 For plans with a calendar-year medical deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan medical deductible has been met. 6 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. 7 Mental health and substance abuse services are accessed through Blue Shield's participating and non-participating providers. 8 Inpatient Services which are Medically Necessary to treat the acute medical complications of detoxification are covered under the medical benefits; see hospitalization services for benefit details. Services for acute medical complications of detoxification are accessed through Blue Shield using Blue Shield's preferred providers or with non-preferred providers. 9 Services may require prior authorization by the Plan. When services are prior authorized, members pay the preferred or participating provider amount. 10 Includes insertion of IUD, as well as injectable and implantable contraceptives for women. 11 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 Part D premium. 12 If the member requests a brand-name 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-name Drug and its generic drug equivalent, as well as the applicable generic drug Copayment. This difference in cost that the member must pay is not applied to their calendar-year medical deductible and is not included in the calendar-year out-of-pocket maximum responsibility calculations. 13 Please note that if you switch from another plan, your prescription drug deductible credit from the previous plan during the calendar year, if applicable, will not carry forward to your new plan. 14 Specialty drugs are covered only when dispensed by select pharmacies in the Specialty Pharmacy Network unless Medically Necessary for a covered emergency. 15 Selected formulary and non-formulary drugs require prior authorization by Blue Shield for Medical Necessity, and when effective, lower cost alternatives are available. 16 Specialty Drugs are specific Drugs used to treat complex or chronic conditions which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the patient or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Infused or Intravenous (IV) medications are not included as Specialty Drugs. These Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy and may require prior authorization for Medical Necessity by Blue Shield. 17 Contraceptive Drugs and Devices covered under the outpatient prescription drug benefits will not be subject to the calendar-year deductible. If a brand-name contraceptive is requested when a generic equivalent is available, the member will be responsible for paying the difference between the cost to Blue Shield for the brand-name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be covered without a copayment. Plan designs may be modified to ensure compliance with federal requirements. An Independent Licensee of the Blue Shield Association 16 Blue Shield of California

19 ASO EPO Plan Benefit Summary (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Highlights: A description of the prescription drug coverage is provided separately THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Effective: January 1, 2015 Preferred Providers 1 $0 per individual / Calendar Year Medical Deductible $0 per family $3,000 per individual / Calendar Year Copayment Maximum $6,000 per family LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Preferred Providers 1 Professional (Physician) Benefits Physician and specialist office visits $30 per visit Teladoc physician consultation $10 per visit CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $50 per visit procedures utilizing nuclear medicine (prior authorization is required) 3 Other outpatient X-ray, pathology and laboratory (Diagnostic testing by $10 per visit providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities) 3 Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $30 per visit Preventive Health Benefits Preventive Health Services (as required by applicable federal law.) No Charge OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery Center 4 $250 per surgery Outpatient surgery in a hospital $250 per surgery Outpatient Services for treatment of illness or injury and necessary No Charge supplies (Except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $50 per visit procedures utilizing nuclear medicine performed in a hospital (prior authorization is required) 3 Other outpatient X-ray, pathology and laboratory performed in a $10 per visit hospital 3 Bariatric Surgery Not Covered HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient Physician Services No Charge Inpatient Non-emergency Facility Services (Semi-private room and board, $200 per day and medically-necessary Services and supplies, including Subacute Care) Bariatric Surgery Not Covered Skilled Nursing Facility Benefits 5 (Combined maximum of up to 100 prior authorized days per Calendar Year; semi-private accommodations) Services by a free-standing Skilled Nursing Facility No Charge Skilled Nursing Unit of a Hospital No Charge EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission (The ER copayment $150 per visit does not apply if the member is directly admitted to the hospital for inpatient services) Emergency room Services resulting in admission (when the member is $200 per day admitted directly from the ER) Emergency room Physician Services No Charge An Independent Licensee of the Blue Shield Association Go to blueshieldca.com/ssl 17

20 AMBULANCE SERVICES Emergency or authorized transport $150 per trip PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug PROSTHETICS/ORTHOTICS 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 Customer Service. Prosthetic equipment and devices (Separate office visit copay may apply) No Charge Orthotic equipment and devices (Separate office visit copay may apply) No Charge DURABLE MEDICAL EQUIPMENT Breast pump No Charge Other Durable Medical Equipment No Charge MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES 6, 7 Inpatient Hospital Services $200 per day Residential Care $200 per day Outpatient Mental Health and Substance Abuse Services $30 per visit HOME HEALTH SERVICES Home health care agency Services No Charge Home infusion/home intravenous injectable therapy and infusion No Charge nursing visits provided by a Home Infusion Agency OTHER Hospice Program Benefits Routine home care No Charge Inpatient Respite Care No Charge 24-hour Continuous Home Care No Charge General Inpatient care No Charge Chiropractic Benefits 5 Chiropractic Services (up to 30 visits per Calendar Year combined with Acupuncture) Acupuncture Benefits Acupuncture (up to 30 visits per Calendar Year combined with Chiropractic services) $30 per visit $30 per visit Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Office location $30 per visit Speech Therapy Benefits Office location $30 per visit Pregnancy and Maternity Care Benefits Prenatal and postnatal Physician office visits (For inpatient hospital services, see "Hospitalization Services.") No Charge Abortion services 9 $30 per visit Family Planning Benefits Counseling and consulting 8 No Charge Tubal ligation No Charge Vasectomy 2 $30 per visit Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see Outpatient Prescription Drug Benefits.) No Charge Diabetes self-management training (by a registered dietician or registered $30 per visit nurse that are certified diabetes educators) Care Outside of Plan Service Area Benefits provided through BlueCard preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider. Within US: BlueCard Program See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit Program, for out-of-state emergency and non-emergency care, are provided at the 1 Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. Preferred providers agree to accept Blue Shield's allowable amount plus the plan s and any applicable member s payment as full payment for covered Services. 2 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. 3 Participating non Hospital based ("freestanding") laboratory or radiology centers may not be available in all areas. Laboratory and radiology Services may also be obtained from a Hospital or from a laboratory and radiology center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 4 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 18 Blue Shield of California

21 5 Services with day or visit limits accrue to the calendar-year day or visit limit maximum regardless of whether the plan deductible has been met. 6 Mental health and substance abuse services are accessed using Blue Shield's participating providers. 7 Inpatient Services which are Medically Necessary to treat the acute medical complications of detoxification are covered under the medical benefits; see hospitalization services for benefit details. Services for acute medical complications of detoxification are accessed through Blue Shield using Blue Shield's preferred providers or with non-preferred providers. 8 Includes insertion of IUD, as well as injectable and implantable contraceptives for women. Plan designs may be modified to ensure compliance with federal requirements. ASO(1/14) JT An Independent Licensee of the Blue Shield Association Go to blueshieldca.com/ssl 19

22 ASO EPO Plan THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Outpatient Prescription Drug Coverage Blue Shield of California Highlight: 3-Tier/Incentive Formulary $0 Calendar-Year Brand-Name Drug Deductible $15 Formulary Generic/$30 Formulary Brand Name/$50 Non-Formulary Brand Name Drug - Retail Pharmacy $30 Formulary Generic/$75 Formulary Brand Name/$150 Non-Formulary Brand Name Drug - Mail Service Covered Services Member Copayment DEDUCTIBLES (Prescription drug coverage benefits are not subject to the medical plan deductible.) Calendar Year Brand Name Drug Deductible None PRESCRIPTION DRUG COVERAGE 1 Participating Pharmacy Non-Participating Pharmacy Retail Prescriptions (up to a 30-day supply) Contraceptive Drugs and Devices 2 $0 per prescription Not Covered Formulary Generic Drugs $15 per prescription Not Covered Formulary Brand Name Drugs 3, 4 $30 per prescription Not Covered Non-Formulary Brand Name Drugs 3, 4 $50 per prescription Not Covered Mail Service Prescriptions (up to a 90-day supply) Contraceptive Drugs and Devices 2 $0 per prescription Not Covered Formulary Generic Drugs $30 per prescription Not Covered Formulary Brand Name Drugs 3, 4 $75 per prescription Not Covered Non-Formulary Brand Name Drugs 3, 4 $150 per prescription Not Covered Specialty Pharmacies (up to a 30-day supply) 5 Specialty Drugs 6 Applicable Drug Tier Copayment Applies Not Covered Note: Oral contraceptives and maintenance medications must be obtained through the mail service prescription drug program once you have received the same medication and dosage through a retail pharmacy for 90 days. 1 Copayments and charges for these covered services are included in the calculation of the member's medical calendar-year copayment maximum and continue to be the member's responsibility after the calendar-year copayment maximum is reached. Please refer to the Plan Contract for exact terms and conditions of coverage. Please note that if you switch from another plan, your prescription drug deductible credit from the previous plan during the calendar year, if applicable, will not carry forward to your new plan. 2 Contraceptive Drugs and Devices covered under the outpatient prescription drug benefits will no longer require a copayment and will not be subject to the calendar-year brand-name drug deductible. However, if a brand-name contraceptive is requested when a generic equivalent is available, the member will still be responsible for paying the difference between the cost to the Plan for the brand-name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be covered without a copayment. 3 Selected formulary and non-formulary drugs require prior authorization by Blue Shield for Medical Necessity, and when effective, lower cost alternatives are available. 4 If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the generic drug copayment plus the difference in cost to Blue Shield between the brand-name drug and its generic drug equivalent. 5 Specialty Drugs are specific Drugs used to treat complex or chronic conditions which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the patient or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Infused or Intravenous (IV) medications are not included as Specialty Drugs. These Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy and may require prior authorization for Medical Necessity by Blue Shield. 6 Specialty drugs are covered only when dispensed by select pharmacies in the Specialty Pharmacy Network unless Medically Necessary for a covered emergency. Note: 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 Part D premium. An Independent Member of the Blue Shield Association 20 Blue Shield of California

23 Important Prescription Drug Information You can find details about your drug coverage three ways: 1. Check your Plan Contract. 2. Go to blueshieldca.com\ssl and log onto My Health Plan from the home page. 3. Call Member Services at the number listed on your Blue Shield member ID card. At Blue Shield of California, we're dedicated to providing you with valuable resources for managing your drug coverage. Go online to the Pharmacy section of blueshieldca.com\ssl and select the Drug Database and Formulary to access a variety of useful drug information that can affect your out-of-pocket expenses, such as: Look up non-formulary drugs with formulary or generic equivalents; Look up drugs that require step therapy or prior authorization; Find specifics about your prescription copayments; Find local network pharmacies to fill your prescriptions. TIPS! Using the convenient mail service pharmacy can save you time and money. If you take a consistent dose of a covered maintenance drug for a chronic condition, such as diabetes or high blood pressure, you can receive up to a 90-day supply through the mail service pharmacy with a reduced copayment. Call the mail service pharmacy at (866) Members using TTY equipment can call TTY/TDD Plan designs may be modified to ensure compliance with federal requirements. ASO (1/14) JT Go to blueshieldca.com/ssl 21