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					  BLUE SHIELD LOGO
  (left-justified with title below)




Health Maintenance Organization (HMO)
Access+ HMO®
Combined Evidence of Coverage and Disclosure Form for the
Basic Plan and the HMO Supplement to Original Medicare Plan

Effective January 1, 2011




Contracted by the CalPERS Board of Administration
Under the Public Employees’ Medical & Hospital Care Act (PEMHCA)
The booklet is divided into the following sections: Section One pertains to members enrolled in the Ba-
sic Health Plan; Section Two pertains to members enrolled in the Supplement to Original Medicare Plan;
Section Three provides information that is common for Basic and Supplement to Original Medicare
Plan members. Each section is clearly marked at the top of each page.

We have included a Summary of Covered Services for Basic and Supplement to Original Medicare Plans
with a comprehensive description following. It will be to your advantage to familiarize yourself with this
booklet before you need services. The Basic Summary of Covered Services can be found on page 5.
The Supplement to Original Medicare Summary of Covered Services can be found on page 63.

Take time to review this booklet. The information contained will be useful throughout the year.

                                                NOTICE
   This Evidence of Coverage and Disclosure Form booklet describes the terms and conditions of
   coverage of your Blue Shield health plan.

   Please read this Evidence of Coverage and Disclosure Form carefully and completely so that you
   understand which services are covered health care services, and the limitations and exclusions that
   apply to your plan. If you or your dependents have special health care needs, you should read
   carefully those sections of the booklet that apply to those needs.

   If you have questions about the benefits of your plan, or if you would like additional information,
   please contact Blue Shield Member Services at the address or telephone number listed on the back
   cover of this booklet.


                                           PLEASE NOTE
   Some hospitals and other providers do not provide one or more of the following services
   that may be covered under your plan contract and that you or your family member might
   need: family planning; contraceptive services, including emergency contraception; sterili-
   zation, including tubal ligation at the time of labor and delivery; infertility treatments; or
   abortion. You should obtain more information before you enroll. Call your prospective
   doctor, medical group, independent practice association, or clinic, or call the health plan
   at Blue Shield’s Member Services telephone number listed at the back of this booklet to
   ensure that you can obtain the health care services that you need.


   This Combined Evidence of Coverage and Disclosure Form constitutes only a summary
   of the Blue Shield Access+ HMO Health Plan. The health plan contract must be con-
   sulted to determine the exact terms and conditions of coverage. However, the statement of
   benefits, exclusions and limitations in this Evidence of Coverage is complete and is incorporated
   by reference into the contract.

   The contract is on file and available for review in the office of the CalPERS Office of Health Plan
   Administration, 400 Q Street, Sacramento, CA 95811, or P.O. Box 720724, Sacramento, CA
   94229-0724. You may purchase a copy of the contract from the CalPERS Office of Health Plan
   Administration for a reasonable duplicating charge.
                                   Amendment #1 to your Access+ HMO
                                Evidence of Coverage and Disclosure Form



                                                         CalPERS
Effective as of January 1, 2011, your Evidence of Coverage and Disclosure Form is amended as follows:


Under A. Hospital Services (page 22), number 2.c. is replaced with the following:

    c. Upper and lower gastrointestinal (GI) endoscopy, cataract surgery, and spinal injection.
         Copayment: $250 per procedure when an outpatient hospital is used in lieu of an ambulatory surgery
         center.




Please be sure to retain this document. It is not a contract but is a part of your Evidence of Coverage and Disclosure Form.




                                                                                                                               An Independent Member of the Blue Shield Association




PH0001 (1/11)
I000-A10778-14 (1/11)
Health Care Reform
The Patient Protection and Affordable Care Act, as amended by the Health Care and Education
Affordability Reconciliation Act of 2010, expands health coverage for various groups and pro-
vides mechanisms to lower costs and increase benefits for Americans with health insurance. As
federal regulations are released for various measures of the law, CalPERS may need to modify
benefits accordingly. For up-to-date information about CalPERS and Health Care Reform,
please refer to the Health Care Reform page on CalPERS On-Line at http://www.calpers.ca.gov.

Your Introduction to the Blue Shield Access+ HMO Health Plan
Welcome to Blue Shield's Access+ HMO Plan. Members enrolled in the Basic Plan may find the
description of their plan beginning on page 7 and members enrolled in the Supplement to Origi-
nal Medicare Plan may find the description of their plan beginning on page 65.

Your interest in the Blue Shield Access+ HMO Health Plan is appreciated. Blue Shield has
served Californians for more than 60 years, and we look forward to serving your health care
needs.

Unlike some HMOs, the Access+ HMO offers you a health plan with a wide choice of physi-
cians, hospitals and non-physician health care practitioners. Access+ HMO Members may also
take advantage of special features such as Access+ Specialist and Access+ Satisfaction. These
features are described fully in this booklet.

You will be able to select your own Personal Physician from the Blue Shield HMO Directory of
general practitioners, family practitioners, internists, obstetricians/gynecologists, and pediatri-
cians. Each of your eligible family members may also select a Personal Physician. All covered
services must be provided by or arranged through your Personal Physician, except for the fol-
lowing: services received during an Access+ Specialist visit, or obstetrical/gynecological
(OB/GYN) services provided by an obstetrician/gynecologist or a family practice physician
within the same medical group or IPA as your Personal Physician, urgent care provided in your
Personal Physician service area by an urgent care clinic when instructed by your assigned medical
group or IPA, or emergency services, or mental health and substance abuse services. See the
How to Use the Plan section for information. Note: A decision will be rendered on all requests
for prior authorization of services as follows: for urgent services and in-area urgent care, as
soon as possible to accommodate the Member’s condition not to exceed 72 hours from receipt
of the request; for other services, within 5 business days from receipt of the request. The treating
provider will be notified of the decision within 24 hours followed by written notice to the pro-
vider and Member within 2 business days of the decision.

You will have the opportunity to be an active participant in your own health care. Working with
the Blue Shield Access+ HMO, we’ll help you make a personal commitment to maintain and,
where possible, improve your health status. Like you, we believe that maintaining a healthy life-
style and preventing illness are as important as caring for your needs when you are ill or injured.

As a partner in health with Blue Shield, you will receive the benefit of Blue Shield’s commitment
to service ... an unparalleled record of more than 60 years.

Please review this booklet which summarizes the coverage and general provisions of the Blue
Shield Access+ HMO.




                                                 1
If you have any questions regarding the information, you may contact us through our Member
Services Department at 1-800-334-5847. The hearing impaired may contact Blue Shield’s Mem-
ber Services Department through Blue Shield’s toll-free text telephone (TTY) number, 1-800-
241-1823.




                                            2
                                                                                                                              Table of Contents
                                                                                                                                                                    Page
Section 1 - Basic Plan
 Summary of Covered Services ..............................................................................................................5
 Benefit Changes for Current Year .......................................................................................................7
 Eligibility..............................................................................................................................................................7
 Enrollment ..........................................................................................................................................................7
 How to Use the Plan .....................................................................................................................................7
   Choice of Physicians and Providers................................................................................................................7
   Payment of Providers ........................................................................................................................................7
   Selecting a Personal Physician..........................................................................................................................8
   Role of the Medical Group or IPA .................................................................................................................8
   Changing Personal Physicians or Designated Medical Group or IPA ......................................................9
   Continuity of Care by a Terminated Provider............................................................................................ 10
   Relationship With Your Personal Physician ............................................................................................... 10
   How to Receive Care...................................................................................................................................... 10
   Use of Personal Physician.............................................................................................................................. 10
   Obstetrical/Gynecological (OB/GYN) Physician Services..................................................................... 11
   Referral to Specialty Services and Second Medical Opinions .................................................................. 11
   Access+ Specialist........................................................................................................................................... 12
   NurseHelp 24/7 and LifeReferrals 24/7..................................................................................................... 13
   Mental Health and Substance Abuse Services............................................................................................ 13
   Emergency Services ........................................................................................................................................ 15
   Urgent Services................................................................................................................................................ 15
   Inpatient, Home Health Care and Other Services..................................................................................... 17
   Member Maximum Calendar Year Copayment ......................................................................................... 17
   Liability of Member for Payment ................................................................................................................. 18
   Limitation of Liability..................................................................................................................................... 18
   Member Identification Card.......................................................................................................................... 18
   Member Services Department ...................................................................................................................... 18
 Rates for Basic Plan .................................................................................................................................. 19
   State Employees and Annuitants.................................................................................................................. 19
   Contracting Agency Employees and Annuitants ....................................................................................... 20
 Benefit Descriptions ................................................................................................................................. 21
   Hospital Services ............................................................................................................................................. 21
   Physician Services (Other Than for Mental Health and Substance Abuse Services) ........................... 22
   Preventive Health Services ............................................................................................................................ 23
   Diagnostic X-ray/Lab Services..................................................................................................................... 23
   Durable Medical Equipment, Prostheses and Orthoses and Other Services ........................................ 23
   Pregnancy and Maternity Care ...................................................................................................................... 25
   Family Planning and Infertility Services ...................................................................................................... 25
   Ambulance Services........................................................................................................................................ 26
   Emergency Services ........................................................................................................................................ 26
   Urgent Services................................................................................................................................................ 28
   Home Health Care Services, PKU-Related Formulas and Special Food Products, and Home Infusion Therapy. 29
   Physical and Occupational Therapy............................................................................................................. 30
   Speech Therapy ............................................................................................................................................... 30
   Skilled Nursing Facility Services ................................................................................................................... 31
   Hospice Program Services............................................................................................................................. 31
   Prescription Drugs.......................................................................................................................................... 34
   Inpatient Mental Health and Substance Abuse Services........................................................................... 39
   Outpatient Mental Health and Substance Abuse Services ....................................................................... 40
   Medical Treatment of the Teeth, Gums, Jaw Joints or Jaw Bones ......................................................... 40

                                                                                 3
Table of Contents
                                                                                                                                                                    Page
  Benefit Descriptions, Continued
    Special Transplant Benefits ............................................................................................................................41
    Organ Transplant Benefits .............................................................................................................................41
    Diabetes Care ...................................................................................................................................................42
    Reconstructive Surgery ...................................................................................................................................42
    Clinical Trials for Cancer................................................................................................................................43
    Additional Services ..........................................................................................................................................43
    Member Maximum Calendar Year Copayment ..........................................................................................44
  Exclusions and Limitations ...................................................................................................................45
    General Exclusions and Limitations.............................................................................................................45
    Medical Necessity Exclusion..........................................................................................................................48
    Limitations for Duplicate Coverage..............................................................................................................48
    Exception for Other Coverage......................................................................................................................49
    Claims and Services Review ...........................................................................................................................49
  General Provisions .....................................................................................................................................49
    Grievance Process ...........................................................................................................................................49
    Appeal Procedure Following Disposition of Plan Grievance Procedure ...............................................51
    CalPERS Administrative Appeal Process ....................................................................................................51
    Department of Managed Health Care Review ............................................................................................52
    Alternate Arrangements..................................................................................................................................52
    Physician-Patient or Plan-Member Relationship ........................................................................................52
  Termination of Group Membership - Continuation of Coverage ....................................52
    Termination of Benefits..................................................................................................................................52
    Reinstatement...................................................................................................................................................53
    Cancellation ......................................................................................................................................................53
    Individual Conversion Plan............................................................................................................................53
    Guaranteed Issue Individual Coverage ........................................................................................................54
    Extension of Benefits......................................................................................................................................54
    COBRA and/or Cal-COBRA........................................................................................................................54
    Continuation of Group Coverage After COBRA and/or Cal-COBRA.................................................56
  Payment by Third Parties .......................................................................................................................57
    Third Party Recovery Process and the Member’s Responsibility ............................................................57
    Workers’ Compensation .................................................................................................................................58
    Coordination of Benefits ................................................................................................................................58
Section 2 - Supplement to Original Medicare Plan ...................................................61
Section 3 - General Information for All Members .....................................................117
  Definitions ......................................................................................................................................................117
   Members Rights and Responsibilities.........................................................................................................123
   Public Policy Participation Procedure ........................................................................................................125
   Confidentiality of Medical Records and Personal Health Information.................................................125
   Access to Information ..................................................................................................................................126
   Non-Assignability ..........................................................................................................................................126
   Facilities...........................................................................................................................................................126
   Independent Contractors .............................................................................................................................127
   Access+ Satisfaction......................................................................................................................................127
   Web Site ..........................................................................................................................................................127
   Utilization Review Process...........................................................................................................................127
   Notice of the Availability of Language Assistance Services....................................................................128
  Service Area ..................................................................................................................................................129


                                                                                  4
BASIC PLAN
THIS IS ONLY A BRIEF SUMMARY. REFER TO THE BENEFIT DESCRIPTIONS AND
LIMITATIONS IN THIS BOOK FOR FURTHER INFORMATION.*
                                Summary of Covered Services
                Category Description                        Member Copayment & Limitations
Hospital
    Inpatient                                                             No Charge
         (includes blood and blood products -
         collection and storage of autologous blood)
    Outpatient                                                         No Charge
         Upper and lower gastrointestinal endoscopy,      $250/procedure at an outpatient hospital
         cataract surgery, and spinal injection
Physician Services
    Office/Home Visits                                                     $15/visit
    Allergy Testing/Treatment                                             No Charge
    Inpatient Hospital Visits                                             No Charge
    Surgery/Anesthesia                                                    No Charge
    Access+ Specialist                                                     $30/visit
Preventive Health                                                         No Charge
Diagnostic X-ray/Lab                                                      No Charge
Durable Medical Equipment                                                 No Charge
    (including orthoses and prostheses)
Pregnancy & Maternity
    Prenatal and Postnatal Physician Office Visits                        No Charge
Family Planning Counseling                                                No Charge
Infertility Testing & Treatment                                    50% of Allowed Charges
Ambulance Services                                                        No Charge
                                                       $50/visit - does not apply if hospitalized or
Emergency Care/Services                                kept for observation and hospital bills for an
                                                       emergency room observation visit
Urgent Services                                                             $15/visit
Home Health Services                                                      No Charge
                                                       No Charge for inpatient visits at a hospital or
Physical/Occupational/Speech Therapy                   skilled nursing facility. $15/visit for outpatient
                                                       and home visits.
Skilled Nursing Care                                   No Charge - up to 100 days per calendar year.
Hospice                                                                   No Charge




                                                  5
BASIC PLAN
THIS IS ONLY A BRIEF SUMMARY. REFER TO THE BENEFIT DESCRIPTIONS AND
LIMITATIONS IN THIS BOOK FOR FURTHER INFORMATION.
                                Summary of Covered Services
                 Category Description                          Member Copayment & Limitations
                                                         Pharmacy: $5 generic, $15 brand name, $45
                                                         non-Formulary, $30 for specialty drugs, 50% of
Prescription Drugs                                       the contracted rate for drugs for erectile dys-
                                                         function/prescription - not to exceed a 30-day
                                                         supply for short-term or acute illness; Mainte-
                                                         nance drugs after 3 months: $10 generic, $25
                                                         brand name, $75 non-Formulary/prescription -
                                                         not to exceed a 30-day supply.
                                                         Mail order: $10 generic, $25 brand name, $75
                                                         non-Formulary/prescription - not to exceed a
                                                         90-day supply for Maintenance drugs; $1,000
                                                         out-of-pocket annual maximum excluding non-
                                                         Formulary drugs.
Mental Health
  Inpatient                                                                   No Charge
   Outpatient                                                                  $15/visit
Substance Abuse
   Inpatient                                                                  No Charge
    Outpatient                                                                 $15/visit
Vision Care
    Eye Refraction to determine need for                 No Charge. (However, this service is limited to one
    corrective lenses                                    visit per calendar year for Members aged 18 and over.
                                                         No limit on number of visits for Members under age
                                                         18.)
    Eyeglasses                                           Not Covered, except for eyeglasses that are
                                                         necessary after cataract surgery.
Hearing Aid Services
  Audiological Evaluation                                                     No Charge
  Hearing Aid up to a maximum of $1,000 per                         Charges in excess of $1,000
  Member every 36 months for both ears for the
  hearing aid instrument and ancillary equipment
Member Maximum Calendar Year Copayment
  Member’s maximum calendar year copayment for           $1,500 per Member
  all covered services except for: Access+ Specialist    $3,000 per Family
  office visits including visits for mental health and
  substance abuse services, infertility services, and
  outpatient prescription drugs

* The statement of benefits, exclusions and limitations in this Evidence of Coverage is complete and
  is incorporated by reference into the contract.




                                                  6
BASIC PLAN
Benefit Changes for Current Year                         CalPERS informational booklet “Health Pro-
Outpatient Hospital                                      gram Guide.” The booklet is prepared by
There is a $250 copayment per endoscopy, cata-           CalPERS Office of Employer and Member
ract surgery, and spinal injection.                      Health Services in Sacramento. A copy of this
                                                         booklet can be ordered using the postage-paid
Hemophilia Infusion                                      order card included in the Open Enrollment
Blue Shield is providing more focused support            mailing, through the CalPERS Web site
to Members who use hemophilia services as de-            (http://www.calpers.ca.gov), by calling CalPERS,
scribed in Section K.                                    or by contacting your Health Benefits Officer.

Prescription Drugs                                       Remember, it is your responsibility to stay in-
Smoking cessation classes are no longer required         formed about your coverage. If you have any
but will be reimbursed up to $100 per year.              questions, consult your Health Benefits Officer
Coverage is added for specialty drugs to treat           in your agency or the retirement system from
complex or chronic conditions, which must be             which you receive your allowance, or contact
obtained from a Blue Shield specialty pharmacy.          CalPERS at the address or telephone number
The copayment reduction is changed to $40 for            shown below:
retail and $70 for mail. Members will be respon-
sible for 50% of the contracted rate for erectile        CalPERS Office of Employer and Member
dysfunction drugs. Non-Formulary drugs are               Health Services, P.O. Box 942714, Sacramento,
excluded from the mail order out-of-pocket an-           CA 94229-2714, Fax (916) 795-1277
nual maximum.
                                                         CalPERS Customer Service and Education Di-
                                                         vision
Reconstructive Surgery
                                                              Toll free 888 CalPERS (or 888-225-7377)
To comply with SB630, Blue Shield is covering
                                                              TTY 1-800-735-2929; (916) 795-3240
dental and orthodontic services that are an inte-
gral part of reconstructive surgery for cleft pal-       Benefits of this Plan become effective at 12:01
ate procedures.                                          a.m. Pacific Time on the eligibility date estab-
                                                         lished by CalPERS.
BENEFITS OF THIS PLAN ARE AVAIL-
ABLE ONLY FOR SERVICES AND SUP-
PLIES FURNISHED DURING THE TERM
                                                         Enrollment
THE PLAN IS IN EFFECT AND WHILE                          Information pertaining to enrollment can be
THE INDIVIDUAL CLAIMING BENEFITS                         found in the CalPERS “Health Program
IS ACTUALLY COVERED BY THE GROUP                         Guide.” To enroll, you must complete CalPERS
AGREEMENT.                                               form HBD-12. If you need assistance in com-
                                                         pleting this form, consult your Health Benefits
IF BENEFITS ARE MODIFIED, THE RE-                        Officer in your agency.
VISED BENEFITS (INCLUDING ANY
REDUCTION IN BENEFITS OR ELIMI-                          How to Use the Plan
NATION OF BENEFITS) APPLY TO SER-                        Choice of Physicians and Providers
VICES OR SUPPLIES FURNISHED ON OR                        PLEASE READ THE FOLLOWING IN-
AFTER THE EFFECTIVE DATE OF                              FORMATION SO YOU WILL KNOW
MODIFICATION. THERE IS NO VESTED                         FROM WHOM OR WHAT GROUP OF
RIGHT TO RECEIVE THE BENEFITS OF                         PROVIDERS HEALTH CARE MAY BE
THIS PLAN.                                               OBTAINED.

Eligibility                                              Payment of Providers
Information pertaining to your eligibility, en-          Blue Shield generally contracts with groups of
rollment, cancellation or termination of cover-          physicians to provide services to Members. A
age, conversion rights, etc. can be found in the         fixed, monthly fee is paid to these groups of

                                                     7
BASIC PLAN
physicians for each Member whose Personal               dress to ensure reasonable access to care, as
Physician is in the group. This payment system,         determined by Blue Shield. If you do not select
capitation, includes incentives to the groups of        a Personal Physician at the time of enrollment,
physicians to manage all services provided to           the Plan will designate a Personal Physician for
Members in an appropriate manner consistent             you and you will be notified of the name of the
with the Agreement.                                     designated Personal Physician. This designation
                                                        will remain in effect until you notify the Plan of
If you want to know more about this payment             your selection of a different Personal Physician.
system, contact Member Services at the number
listed on the back cover of this booklet or talk        A Personal Physician must also be selected for a
to your Plan provider.                                  newborn or child placed for adoption, prefera-
                                                        bly prior to birth or adoption, but always within
Selecting a Personal Physician                          31 days from the date of birth or placement for
A close physician-to-patient relationship is an         adoption. You may designate a pediatrician as
important ingredient that helps to ensure the           the Personal Physician for your child. The Per-
best medical care. Each Member is therefore re-         sonal Physician selected for the month of birth
quired to select a Personal Physician at the time       must be in the same medical group or IPA as
of enrollment. Family members can choose dif-           the mother’s Personal Physician when the new-
ferent Personal Physicians in different medical         born is the natural child of the mother. If the
groups or IPAs, except as described for new-            mother of the newborn is not enrolled as a
borns below. This decision is an important one          Member or if the child has been placed with the
because your Personal Physician will:                   subscriber for adoption, the Personal Physician
                                                        selected must be a physician in the same medical
 • Help you decide on actions to maintain               group or IPA as the subscriber. If you do not
   and improve your total health;                       select a Personal Physician within 31 days fol-
 • Coordinate and direct all of your medical            lowing the birth or placement for adoption, the
   care needs;                                          Plan will designate a Personal Physician from
 • Authorize emergency services when ap-                the same medical group or IPA as the natural
   propriate;                                           mother or the subscriber. This designation will
 • Work with your medical group or IPA to               remain in effect for the first calendar month
   arrange your referrals to specialty physi-           during which the birth or placement for adop-
   cians, hospitals and all other health ser-           tion occurred. If you want to change the Per-
   vices, including requesting any prior                sonal Physician for the child after the month of
   authorization you will need;                         birth or placement for adoption, see the section
 • Prescribe those lab tests, x-rays and ser-           below on Changing Personal Physicians or Des-
   vices you require;                                   ignated Medical Group or IPA. If your child is
 • If you request it, assist you in obtaining           ill during the first month of coverage, be sure to
   prior approval from the Mental Health                read the information about changing Personal
   Service Administrator (MHSA) for men-                Physicians during a course of treatment or hos-
   tal health and substance abuse services.             pitalization.
   See the Mental Health and Substance
                                                        Remember that if you want your child covered
   Abuse Services paragraphs in the How
                                                        beyond the 31 days from the date of birth or
   to Use the Plan section for information;
                                                        placement for adoption, you should contact
   and,
                                                        CalPERS Office of Employer and Member
 • Assist you in applying for admission into            Health Services and Blue Shield to add your
   a hospice program through a participat-              child to your coverage.
   ing hospice agency when necessary.
                                                        Role of the Medical Group or IPA
To ensure access to services, each Member must
select a Personal Physician who is located suffi-       Most Blue Shield Access+ HMO Personal Phy-
ciently close to the Member’s home or work ad-          sicians contract with medical groups or IPAs to

                                                    8
BASIC PLAN
share administrative and authorization responsi-            specialists affiliated with the new medical group
bilities with them. (Of note, some Personal Phy-            or IPA. The change will be effective the first day
sicians contract directly with Blue Shield.) Your           of the month following notice of approval by
Personal Physician coordinates with your desig-             Blue Shield. Once your Personal Physician
nated medical group or IPA to direct all of your            change is effective, all care must be provided or
medical care needs and refer you to specialists             arranged by the new Personal Physician, except
or hospitals within your designated medical                 for OB/GYN services provided by an obstetri-
group or IPA unless because of your health                  cian/gynecologist or a family practice physician
condition, care is unavailable within the medical           within the same medical group or IPA as your
group or IPA.                                               Personal Physician and Access+ Specialist visits.
                                                            Once your medical group or IPA change is ef-
Your designated medical group or IPA (or Blue               fective, all previous authorizations for specialty
Shield when noted on your identification card)              care or procedures are no longer valid and must
ensures that a full panel of specialists is available       be transitioned to specialists affiliated with the
to provide your health care needs and helps                 new medical group or IPA, even if you remain
your Personal Physician manage the utilization              with the same Personal Physician. Member Ser-
of your health plan benefits by ensuring that re-           vices will assist you with the timing and choice
ferrals are directed to providers who are con-              of a new Personal Physician or medical group or
tracted with them. Medical groups or IPAs also              IPA.
have admitting arrangements with hospitals con-
tracted with Blue Shield in their area and some             Voluntary medical group or IPA changes are
have special arrangements that designate a spe-             not permitted during the third trimester of preg-
cific hospital as “in network.” Your designated             nancy or while confined to a hospital. The effec-
medical group or IPA works with your Personal               tive date of your new medical group or IPA will
Physician to authorize services and ensure that             be the first of the month following discharge
that service is performed by their in network               from the hospital, or when pregnant, following
provider.                                                   the completion of post-partum care.

The name of your Personal Physician and your                Additionally, changing your Personal Physician
designated medical group or IPA (or, “Blue                  or designated medical group or IPA during a
Shield Administered”) is listed on your Access+             course of treatment may interrupt the quality
HMO identification card. The Blue Shield                    and continuity of your health care. For this rea-
HMO Member Services Department can answer                   son, the effective date of your new Personal
any questions you may have about changing the               Physician or designated medical group or IPA,
medical group or IPA designated for your Per-               when requested during a course of treatment,
sonal Physician and whether the change would                will be the first of the month following the date
affect your ability to receive services from a par-         it is medically appropriate to transfer your care
ticular specialist or hospital.                             to your new Personal Physician or designated
                                                            medical group or IPA, as determined by the
Changing Personal Physicians or                             Plan.
Designated Medical Group or IPA
You or your dependent may change Personal                   Exceptions must be approved by the Blue
Physicians or designated medical group or IPA               Shield Medical Director. For information about
by calling the Member Services Department at                approval for an exception to the above provi-
1-800-334-5847. Some Personal Physicians are                sion, please contact Member Services.
affiliated with more than one medical group or
IPA. If you change to a medical group or IPA                If your Personal Physician discontinues partici-
with no affiliation to your Personal Physician,             pation in the Plan, Blue Shield will notify you in
you must select a new Personal Physician affili-            writing and designate a new Personal Physician
ated with the new medical group or IPA and                  for you in case you need immediate medical
transition any specialty care you are receiving to          care. You will also be given the opportunity to


                                                        9
BASIC PLAN
select a new Personal Physician of your own               Your Personal Physician will advise you if he be-
choice within 15 days of this notification. Your          lieves that there is no professionally acceptable
selection must be approved by Blue Shield prior           alternative to a recommended treatment or pro-
to receiving any services under the Plan. In the          cedure. If you continue to refuse to follow the
event that your selection has not been approved           recommended treatment or procedure, Member
and an emergency arises, see I. Emergency Ser-            Services can assist you in the selection of an-
vices in the Benefit Descriptions section for in-         other Personal Physician.
formation.
                                                          Repeated failures to establish a satisfactory rela-
IT IS IMPORTANT TO KNOW THAT                              tionship with a Personal Physician may result in
WHEN YOU ENROLL IN THE BLUE                               termination of your coverage, but only after you
SHIELD ACCESS+ HMO, SERVICES ARE                          have been given access to other available Per-
PROVIDED THROUGH THE PLAN’S DE-                           sonal Physicians and have been unsuccessful in
LIVERY SYSTEM, BUT THE CONTINUED                          establishing a satisfactory relationship. Any such
PARTICIPATION OF ANY ONE DOCTOR,                          termination will take place in accordance with
HOSPITAL OR OTHER PROVIDER CAN-                           written procedures established by Blue Shield
NOT BE GUARANTEED.                                        and only after written notice to the Member
                                                          which describes the unacceptable conduct, pro-
Continuity of Care by a Terminated                        vides the Member with an opportunity to re-
Provider                                                  spond and warns the Member of the possibility
Members who are being treated for acute condi-            of termination.
tions, serious chronic conditions, pregnancies
(including immediate postpartum care), or ter-            How to Receive Care
minal illness; or who are children from birth to          Use of Personal Physician
36 months of age; or who have received au-                At the time of enrollment, you will choose a
thorization from a now-terminated provider for            Personal Physician who will coordinate all cov-
surgery or another procedure as part of a docu-           ered services. You must contact your Personal
mented course of treatment can request comple-            Physician for all health care needs, including
tion of care in certain situations with a provider        preventive services, routine health problems,
who is leaving the Blue Shield provider network.          consultations with Plan specialists (except as
Contact Member Services to receive information            provided under Obstetrical/Gynecological
regarding eligibility criteria and the policy and         (OB/GYN) Physician Services, Access+ Spe-
procedure for requesting continuity of care from          cialist, and Mental Health and Substance Abuse
a terminated provider.                                    Services), admission into a hospice program
                                                          through a participating hospice agency, emer-
Relationship With Your Personal                           gency services, urgent services and for hospitali-
Physician                                                 zation. The Personal Physician is responsible for
The physician-patient relationship you and your           providing primary care and coordinating or ar-
Personal Physician establish is very important.           ranging for referral to other necessary health
The best effort of your Personal Physician will           care services and requesting any needed prior
be used to ensure that all medically necessary            authorization. You should cancel any scheduled
and appropriate professional services are pro-            appointments at least 24 hours in advance. This
vided to you in a manner compatible with your             policy applies to appointments with or arranged
wishes. If your Personal Physician recommends             by your Personal Physician or the Mental Health
procedures or treatments which you refuse, or             Service Administrator (MHSA) and self-
you and your Personal Physician fail to establish         arranged appointments to an Access+ Specialist
a satisfactory relationship, you may select a dif-        or for OB/GYN services. Because your physi-
ferent Personal Physician. Member Services can            cian has set aside time for your appointments in
assist you with this selection.                           a busy schedule, you need to notify the office
                                                          within 24 hours if you are unable to keep the
                                                          appointment. That will allow the office staff to

                                                     10
BASIC PLAN
offer that time slot to another patient who needs         The OB/GYN physician services are separate
to see the physician. Some offices may advise             from the Access+ Specialist feature described
you that a fee (not to exceed your copayment)             below.
will be charged for missed appointments unless
you give 24-hour advance notice or missed the             Referral to Specialty Services and
appointment because of an emergency situation.            Second Medical Opinions
                                                          Although self-referrals to Plan specialists are al-
If you have not selected a Personal Physician for         lowed through the Access+ Specialist feature
any reason, you must contact Member Services              described below, Blue Shield encourages you to
at 1-800-334-5847, Monday through Friday, be-             receive specialty services through a referral from
tween 7 a.m. and 7 p.m. to select a Personal              your Personal Physician. The Personal Physician
Physician to obtain benefits.                             is responsible for coordinating all of your health
                                                          care needs and can best direct you for required
Obstetrical/Gynecological (OB/GYN)                        specialty services. Your Personal Physician will
Physician Services                                        generally refer you to a Plan specialist or Plan
A female Member may arrange for obstetrical               non-physician health care practitioner in the
and/or gynecological (OB/GYN) services by an              same medical group or IPA as your Personal
obstetrician/gynecologist or a family practice            Physician, but you can be referred outside the
physician who is not her designated Personal              medical group or IPA if the type of specialist or
Physician. A referral from your Personal Physi-           non-physician health care practitioner needed is
cian or from the affiliated medical group or IPA          not available within your Personal Physician’s
is not needed. However, the obstetri-                     medical group or IPA. Your Personal Physician
cian/gynecologist or family practice physician            will request any necessary prior authorization
must be in the same medical group or IPA as               from your medical group or IPA. For mental
her Personal Physician.                                   health and substance abuse services, see the
                                                          Mental Health and Substance Abuse Services
Obstetrical and gynecological services are de-            paragraphs in the How to Use the Plan section
fined as:                                                 for information regarding how to access care.
                                                          The Plan specialist or Plan non-physician health
 • Physician services related to prenatal,                care practitioner will provide a complete report
   perinatal and postnatal (pregnancy) care,              to your Personal Physician so that your medical
 • Physician services provided to diagnose                record is complete.
   and treat disorders of the female repro-
   ductive system and genitalia,                          If there is a question about your diagnosis, plan
 • Physician services for treatment of dis-               of care, or recommended treatment, including
   orders of the breast,                                  surgery, or if additional information concerning
 • Routine annual gynecological examina-                  your condition would be helpful in determining
   tions/annual well-woman examinations.                  the diagnosis and the most appropriate plan of
                                                          treatment, or if the current treatment plan is not
It is important to note that services by an obste-        improving your medical condition, you may ask
trician/gynecologist or a family practice physi-          your Personal Physician to refer you to another
cian outside of the Personal Physician’s medical          physician for a second medical opinion. The
group or IPA without authorization will not be            second opinion will be provided on an expe-
covered under this Plan. Before making the ap-            dited basis, where appropriate. If you are re-
pointment, the Member should call the Member              questing a second opinion about care you
Services Department at 1-800-334-5847 to con-             received from your Personal Physician, the sec-
firm that the obstetrician/gynecologist or family         ond opinion will be provided by a physician
practice physician is in the same medical group           within the same medical group or IPA as your
or IPA as her Personal Physician.                         Personal Physician. If you are requesting a sec-
                                                          ond opinion about care received from a special-
                                                          ist, the second opinion may be provided by any

                                                     11
BASIC PLAN
Plan specialist of the same or equivalent spe-             Personal Physician, subject to the limitations de-
cialty. All second opinion consultations must be           scribed below. Access+ Specialist office visits
authorized. Your Personal Physician may also               are available only to Members whose Personal
decide to offer such a referral even if you do not         Physicians belong to a medical group or IPA
request it. State law requires that health plans           that participates as an Access+ Provider. Refer
disclose to Members, upon request, the time-               to the HMO Physician and Hospital Directory
lines for responding to a request for a second             or call Blue Shield Member Services at 1-800-
medical opinion. To request a copy of these                334-5847 to determine whether a medical group
timelines, you may call the Member Services                or IPA is an Access+ Provider.
Department at the number listed on the back
cover of this booklet.                                     When you arrange for Access+ Specialist visits
                                                           without a referral from your Personal Physician,
If your Personal Physician belongs to a medical            you will be responsible for a $30 copayment for
group or IPA that participates as an Access+               each Access+ Specialist visit. This copayment is
Provider, you may also arrange a second opinion            in addition to any copayments that you may in-
visit with another physician in the same medical           cur for specific benefits as described in the
group or IPA without a referral, subject to the            Summary of Covered Services. Each follow-up
limitations described in the Access+ Specialist            office visit with the Plan specialist which is not
paragraphs later in this section.                          referred or authorized by your Personal Physi-
                                                           cian is a separate Access+ Specialist visit and re-
To obtain referral for specialty services, includ-         quires a separate $30 copayment.
ing lab and x-ray, you must first contact your
Personal Physician. If the Personal Physician de-          You should cancel any scheduled Access+ Spe-
termines that specialty services are medically             cialist appointment at least 24 hours in advance.
necessary, the physician will complete a referral          Unless you give 24-hour advance notice or miss
form and request necessary authorization. Your             the appointment because of an emergency situa-
Personal Physician will designate the Plan pro-            tion, the physician’s office may charge you a fee
vider from whom you will receive services.                 as much as the Access+ Specialist copayment.
When no Plan provider is available to perform
the needed service, the Personal Physician will            Note: When you receive a referral from your
refer you to a non-Plan provider after obtaining           Personal Physician to obtain services from a
authorization. This authorization procedure is             specialist, you are responsible for the physician
handled for you by your Personal Physician.                services copayment.

In certain situations where the Member's medi-             For Access+ Specialist visits for mental health
cal condition or disease is life-threatening, de-          and substance abuse services, see the following
generative, or disabling and requires specialized          Mental Health and Substance Abuse Services
medical care over a prolonged period of time,              paragraphs.
the Personal Physician may make a standing re-
ferral (more than one visit) to an appropriate             The Access+ Specialist visit includes:
specialist.
                                                             • An examination or other consultation
Referral by a Personal Physician does not guar-                provided to you by a medical group Plan
antee coverage for referral services. The eligibil-            specialist without referral from your Per-
ity provisions, exclusions and limitations will                sonal Physician;
apply.                                                       • Conventional x-rays such as chest x-rays,
                                                               abdominal flat plates, and x-rays of
Access+ Specialist                                             bones to rule out the possibility of frac-
You may arrange an office visit with a Plan spe-               ture (but does not include any diagnostic
cialist in the same medical group or IPA as your               imaging such as CT, MRI, or bone den-
Personal Physician without a referral from your                sity measurement);


                                                      12
BASIC PLAN
 • Laboratory services;                                 hours a day, to receive confidential advice and
 • Diagnostic or treatment procedures                   information about minor illnesses and injuries,
   which a Plan specialist would regularly              chronic conditions, fitness, nutrition and other
   provide under a referral from the Per-               health-related topics.
   sonal Physician.
                                                        Psychosocial support through LifeReferrals
An Access+ Specialist visit does not include:           24/7 - Members may call 1-800-985-2405 on a
                                                        24-hour basis for confidential psychosocial sup-
 • Any services which are not covered or                port services. Professional counselors will pro-
   which are not medically necessary;                   vide support through assessment, referrals and
 • Services provided by a non-Access+                   counseling. Note: See the following Mental
   Provider (such as podiatry and physical              Health and Substance Abuse Services para-
   therapy), except for the x-ray and labora-           graphs for important information concerning
   tory services described above;                       this feature.
 • Allergy testing;
 • Endoscopic procedures;                               Mental Health and Substance Abuse
 • Any diagnostic imaging including CT,                 Services
   MRI, or bone density measurement;                    Blue Shield of California has contracted with a
 • Injectables, chemotherapy or other infu-             Mental Health Service Administrator (MHSA)
   sion drugs, other than vaccines and anti-            to underwrite and deliver all mental health and
   biotics;                                             substance abuse services through a unique net-
 • Infertility services;                                work of mental health Participating Providers.
 • Emergency services;                                  (See Mental Health Service Administrator under
                                                        the Definitions section for more information.)
 • Urgent services;
                                                        All non-emergency mental health and substance
 • Inpatient services, or any services which
                                                        abuse services, except for Access+ Specialist
   result in a facility charge, except for rou-
                                                        visits, must be arranged through the MHSA.
   tine x-ray and laboratory services;
                                                        Members do not need to arrange for mental
 • Services for which the medical group or              health and substance abuse services through
   IPA routinely allows the Member to self-             their Personal Physician. (See 1. Prior Authori-
   refer without authorization from the                 zation paragraphs below.)
   Personal Physician;
 • OB/GYN services by an obstetrician/                  All mental health and substance abuse services,
   gynecologist or a family practice physi-             except for emergency or urgent services, must
   cian within the same medical group or                be provided by a MHSA Participating Provider.
   IPA as the Personal Physician;                       MHSA Participating Providers are indicated in
 • Internet-based consultations.                        the Blue Shield of California Behavioral Health
                                                        Provider Directory. Members may contact the
NurseHelp 24/7 and LifeReferrals 24/7                   MHSA directly for information on, and to select
NurseHelp 24/7 and LifeReferrals 24/7 pro-              a MHSA Participating Provider by calling 1-866-
grams provide Members with no charge, confi-            505-3409. Your Personal Physician may also
dential telephone support for information,              contact the MHSA to obtain information re-
consultations, and referrals for health and psy-        garding MHSA Participating Providers for you.
chosocial issues. Members may obtain these ser-
vices by calling a 24-hour, toll-free telephone         Non-emergency mental health and substance
number. There is no charge for these services.          abuse services received from a provider who
                                                        does not participate in the MHSA Participating
These programs include:                                 Provider network will not be covered, except as
                                                        stated herein, and all charges for these services
NurseHelp 24/7 - Members may call a regis-              will be the Member’s responsibility. This limita-
tered nurse toll free via 1-877-304-0504, 24            tion does not apply with respect to emergency

                                                   13
BASIC PLAN
services. In addition, when no MHSA Partici-                 written evaluation which are not covered
pating Provider is available to perform the                  under this benefit.
needed service, the MHSA will refer you to a
non-Plan provider and authorize services to be               The Member may arrange for an Access+
received.                                                    Specialist office visit for mental health and
                                                             substance abuse services without a referral
For complete information regarding benefits for              from the MHSA, as long as the provider is a
mental health and substance abuse services, see              MHSA Participating Provider. Refer to the
Q. Inpatient Mental Health and Substance                     Blue Shield of California Behavioral Health
Abuse Services and R. Outpatient Mental                      Provider Directory or call the MHSA at
Health and Substance Abuse Services in the                   1-866-505-3409 to determine MHSA Par-
Benefit Descriptions section.                                ticipating Providers. Members will be re-
                                                             sponsible for a $30 copayment for each
1. Prior Authorization                                       Access+ Specialist visit for mental health
                                                             and substance abuse services. Each follow-
   All non-emergency mental health and sub-                  up office visit for mental health and sub-
   stance abuse services must be prior author-               stance abuse services which is not referred
   ized by the MHSA. For prior authorization                 or authorized by the MHSA is a separate
   of mental health and substance abuse ser-                 Access+ Specialist visit and requires a sepa-
   vices, the Member should contact the                      rate $30 copayment.
   MHSA at 1-866-505-3409.
                                                          3. Psychosocial Support through LifeReferrals
   Failure to receive prior authorization for                24/7
   mental health and substance abuse services
   as described, except for emergency and ur-                Notwithstanding the benefits provided un-
   gent services, will result in the Member be-              der R. Outpatient Mental Health and Sub-
   ing totally responsible for all costs for these           stance Abuse Services, the Member also
   services.                                                 may call 1-800-985-2405 on a 24-hour basis
                                                             for confidential psychosocial support ser-
   Note: The MHSA will render a decision on                  vices. Professional counselors will provide
   all requests for prior authorization of ser-              support through assessment, referrals and
   vices as follows:                                         counseling.
   • for urgent services, as soon as possible                In California, support may include, as ap-
     to accommodate the Member’s condi-                      propriate, a referral to a counselor for a
     tion not to exceed 72 hours from re-                    maximum of three no charge, face-to-face
     ceipt of the request;                                   visits within a 6-month period.
   • for other services, within 5 business
     days from receipt of the request. The                   In the event that the services required of a
     treating provider will be notified of the               Member are most appropriately provided by
     decision within 24 hours followed by                    a psychiatrist or the condition is not likely to
     written notice to the provider and                      be resolved in a brief treatment regimen, the
     Member within 2 business days of the                    Member will be referred to the MHSA in-
     decision.                                               take line to access his mental health and
                                                             substance abuse services which are de-
2. Access+ Specialist Visits for Mental Health               scribed under R. Outpatient Mental Health
   and Substance Abuse Services                              and Substance Abuse Services.

   The Access+ Specialist feature is available
   for all mental health and substance abuse
   services except for psychological testing and


                                                     14
BASIC PLAN
Emergency Services                                      Urgent Services
What is an Emergency?                                   The Blue Shield Access+ HMO provides cover-
An emergency means an unexpected medical                age for you and your family for your urgent ser-
condition manifesting itself by acute symptoms          vice needs when you or your family are
of sufficient severity (including severe pain)          temporarily traveling outside of your Personal
such that a layperson who possesses an average          Physician service area.
knowledge of health and medicine could rea-
sonably assume that the absence of immediate            Urgent services are defined in Section 3, under
medical attention could be expected to result in        Definitions. Out-of-area follow-up care is de-
any of the following: (1) placing the Member’s          fined in Section 3, under Definitions.
health in serious jeopardy, (2) serious impair-
ment to bodily functions, (3) serious dysfunc-          (Urgent care) While in your Personal Physi-
tion of any bodily organ or part. If you receive        cian Service Area
non-authorized services in a situation that Blue        If you require urgent care for a condition that
Shield determines was not a situation in which a        could reasonably be treated in your Personal
reasonable person would believe that an emer-           Physician’s office or in an urgent care clinic (i.e.,
gency condition existed, you will be responsible        care for a condition that is not such that the ab-
for the costs of those services.                        sence of immediate medical attention could rea-
                                                        sonably be expected to result in placing your
Members who reasonably believe that they have           health in serious jeopardy, serious impairment to
an emergency medical or mental health condi-            bodily functions, or serious dysfunction of any
tion which requires an emergency response are           bodily organ or part), you must first call your
encouraged to appropriately use the “911”               Personal Physician. However, you may go di-
emergency response system where available.              rectly to an urgent care clinic when your as-
                                                        signed medical group or IPA has provided you
What to do in case of Emergency:                        with instructions for obtaining care from an ur-
Life Threatening                                        gent care clinic in your Personal Physician ser-
   Obtain care immediately.                             vice area.

   Contact your Personal Physician no later             Outside of California or the United States
   than 24 hours after the onset of the emer-           The Blue Shield Access+ HMO provides cover-
   gency, or as soon as it is medically possible        age for you and your family for your urgent ser-
   for the Member to provide notice.                    vice needs when you or your family are
                                                        temporarily traveling outside of California. You
Non-Life Threatening                                    can receive urgent care services from any pro-
   Consult your Personal Physician, anytime             vider; however, using the BlueCard® Program,
   day or night, regardless of where you are            described below, can be more cost-effective and
   prior to receiving medical care.                     eliminate the need for you to pay for the services
                                                        when they are rendered and submit a claim for re-
Follow-Up Care                                          imbursement.
   Follow-up care, which is any care provided           Through the BlueCard Program, you can access
   after the initial emergency room visit, must         urgent care services across the country and
   be provided or authorized by your Personal           around the world. While traveling within the
   Physician.                                           United States, you can locate a BlueCard Pro-
                                                        gram participating provider any time by calling
For a complete description of the Emergency
                                                        1-800-810-BLUE (2583) or going on-line at
Services benefit and applicable copayments, see
                                                        http://www.bcbs.com and selecting the “Find a
I. Emergency Services in the Benefit Descrip-
                                                        Doctor or Hospital” tab. If you are traveling out-
tions section.
                                                        side of the United States, you can call 1-804-673-


                                                   15
BASIC PLAN
1177 collect 24 hours a day to locate a BlueCard           future to correct for over- or underestimation of
Worldwide® Network provider.                               past prices. However, the amount you pay is
                                                           considered a final price.
Out-of-area follow-up care is covered and may
be received through the BlueCard Program par-              Statutes in a small number of states may require
ticipating provider network or from any pro-               the local Blue Cross and/or Blue Shield plan to
vider. However, authorization by Blue Shield is            use a basis for calculating Member liability for
required for more than two out-of-area follow-             covered services that does not reflect the entire
up care outpatient visits or for care that involves        savings realized, or expected to be realized, on a
a surgical or other procedure or inpatient stay.           particular claim or to add a surcharge. Should
The Blue Shield Access+ HMO may direct the                 any state statutes mandate Member liability cal-
patient to receive the additional follow-up ser-           culation methods that differ from the usual
vices from the Personal Physician.                         BlueCard Program method noted above or re-
                                                           quire a surcharge, Blue Shield of California
If services are not received from a BlueCard               would then calculate your liability for any cov-
Program participating provider, you may be re-             ered health care services in accordance with the
quired to pay the provider for the entire cost of          applicable state statute in effect at the time you
the service and submit a claim to the Blue Shield          received your care.
Access+ HMO. Claims for urgent services and
out-of-area follow-up care rendered outside of             For any other providers, the amount you pay, if
California and not provided by a BlueCard Pro-             not subject to a flat dollar copayment, is calcu-
gram participating provider will be reviewed ret-          lated on the provider’s billed charges for your
rospectively for coverage.                                 covered services.

Under the BlueCard Program, when you obtain                Within California
health care services outside of California, the            If you are temporarily traveling within Califor-
amount you pay, if not subject to a flat dollar            nia, but are outside of your Personal Physician
copayment, is calculated on the lower of:                  service area, if possible you should call Blue
                                                           Shield Member Services at 1-800-334-5847 for
1. The allowed charges for your covered ser-               assistance in receiving urgent services through a
   vices, or                                               Blue Shield of California Plan provider. You may
                                                           also locate a Plan provider by visiting our web site
2. The negotiated price that the local Blue                at http://www.blueshieldca.com. However, you
   Cross and/or Blue Shield plan passes on to              are not required to use a Blue Shield of California
   us.                                                     Plan provider to receive urgent services; you may
                                                           use any provider.
Often, this "negotiated price" will consist of a
simple discount which reflects the actual price            Follow-up care is also covered through a Blue
paid by the local Blue Cross and/or Blue Shield            Shield of California Plan provider and may also
plan. But sometimes it is an estimated price that          be received from any provider. However, when
factors into the actual price expected settle-             outside your Personal Physician service area au-
ments, withholds, any other contingent payment             thorization by Blue Shield is required for more
arrangements and non-claims transactions with              than two out-of-area follow-up care outpatient
your health care provider or with a specified              visits or for care that involves a surgical or other
group of providers. The negotiated price may               procedure or inpatient stay. The Blue Shield Ac-
also be billed charges reduced to reflect an aver-         cess+ HMO may direct the patient to receive the
age expected savings with your health care pro-            additional follow-up services from the Personal
vider or with a specified group of providers.              Physician.
The price that reflects average savings may re-
sult in greater variation (more or less) from the          If services are not received from a Blue Shield
actual price paid than will the estimated price.           of California Plan provider, you may be required
The negotiated price will also be adjusted in the

                                                      16
BASIC PLAN
to pay the provider for the entire cost of the            Member Maximum Calendar Year
service and submit a claim to the Blue Shield             Copayment
Access+ HMO. Claims for urgent services ob-               Your maximum copayment responsibility each
tained outside of your Personal Physician ser-            calendar year for covered services, except those
vice area within California will be reviewed              listed below, is $1,500 per Member and $3,000
retrospectively for coverage.                             per family.
When you receive covered urgent services out-             Once a Member’s maximum copayment respon-
side your Personal Physician service area within          sibility has been met, the Plan will pay 100% of
California, the amount you pay, if not subject to         the allowed charges for that Member’s covered
a flat dollar copayment, is calculated on Blue            services for the remainder of that calendar year,
Shield’s allowed charges.                                 except as described below. Additionally, for
                                                          Plans with a Member and a family maximum
See J. Urgent Services in the Benefit Descrip-            copayment responsibility, once the family
tions section for benefit description, applicable         maximum copayment responsibility has been
copayment information, and information on                 met, the Plan will pay 100% of the allowed
payment responsibility and claims submission.             charges for the subscriber’s and all covered de-
                                                          pendents’ covered services for the remainder of
Inpatient, Home Health Care                               that calendar year, except as described below.
and Other Services
The Personal Physician is responsible for ob-             Copayments for the following services do not
taining prior authorization before you can be             apply towards the Member maximum calendar
admitted to the hospital or a skilled nursing fa-         year copayment responsibility:
cility, including subacute care admissions, except
for mental health and substance abuse services            1. Access+ Specialist office visits including vis-
which are described in the previous Mental                   its for mental heath and substance abuse;
Health and Substance Abuse Services section.
The Personal Physician is responsible for ob-             2. Infertility services;
taining prior authorization before you can re-
ceive home health care and certain other                  3. Outpatient prescription drugs.
services or before you can be admitted into a
hospice program through a participating hospice           Charges for services not covered and services
agency. If the Personal Physician determines              not prior approved by the Personal Physician,
that you should receive any of these services, he         except those meeting the emergency and urgent
or she will request authorization. Your Personal          care requirements, are your responsibility, do
Physician will arrange for your admission to the          not apply towards the Member maximum calen-
hospital, skilled nursing facility, or a hospice          dar year copayment responsibility, and may
program through a participating hospice agency,           cause your payment responsibility to exceed the
as well as for the provision of home health care          Member maximum calendar year copayment re-
and other services.                                       sponsibility defined above.

For hospital admissions for mastectomies or               Note that copayments and charges for services
lymph node dissections, the length of hospital            not accruing to the Member maximum calendar
stays will be determined solely by the Member’s           year copayment continue to be the Member's re-
physician in consultation with the Member. For            sponsibility after the calendar year copayment
information regarding length of stay for mater-           maximum is reached.
nity or maternity-related services, see F. Preg-
nancy and Maternity Care, for information                 Note: It is your responsibility to maintain accu-
relative to the Newborns’ and Mothers’ Health             rate records of your copayments and to deter-
Protection Act.                                           mine and notify Blue Shield when the Member



                                                     17
BASIC PLAN
maximum calendar year copayment responsibil-              ter the benefit description. There are no de-
ity has been reached.                                     ductibles to be met.

You must notify Blue Shield Member Services               Limitation of Liability
in writing when you feel that your Member                 Members shall not be responsible to Plan pro-
maximum calendar year copayment responsibil-              viders for payment for services if they are a
ity has been reached. At that time, you must              benefit of the Plan. When covered services are
submit complete and accurate records to Blue              rendered by a Plan provider, the Member is re-
Shield substantiating your copayment expendi-             sponsible only for the applicable copayments,
tures for the period in question. Member Ser-             except as set forth in the Third Party Recovery
vices address and telephone number may be                 Process and the Member’s Responsibility sec-
found on the back cover of this booklet.                  tion. Members are responsible for the full
                                                          charges for any non-covered services they ob-
Liability of Member for Payment                           tain.
It is important to note that all services except
for those meeting the emergency and out of ser-           Member Identification Card
vice area urgent services requirements, Access+           You will receive your Blue Shield Access+
Specialist visits, hospice program services re-           HMO identification card after enrollment. If
ceived from a participating hospice agency after          you do not receive your identification card or if
the Member has been accepted into the hospice             you need to obtain medical or prescription ser-
program, OB/GYN services by an obstetri-                  vices before your card arrives, contact the Blue
cian/gynecologist or a family practice physician          Shield Member Services Department so that
who is in the same medical group or IPA as the            they can coordinate your care and direct your
Personal Physician, and all mental health and             Personal Physician or pharmacy.
substance abuse services, must have prior au-
thorization by the Personal Physician, medical            Member Services Department
group or IPA. The Member will be responsible              For all services other than mental health and
for payment of services that are not authorized           substance abuse
or those that are not an emergency or covered             If you have a question about services, providers,
out of service area urgent service procedures.            benefits, how to use this plan, or concerns re-
(See the previous Urgent Services paragraphs              garding the quality of care or access to care that
for information on receiving urgent services out          you have experienced, you should call the Blue
of the service area but within California.) Mem-          Shield Member Services Department at 1-800-
bers must obtain services from the Plan provid-           334-5847. The hearing impaired may contact
ers that are authorized by their Personal                 Blue Shield’s Member Services Department
Physician, medical group or IPA and, for all              through Blue Shield’s toll-free TTY number,
mental health and substance abuse services,               1-800-241-1823. Member Services can answer
from MHSA Participating Providers. Hospice                many questions over the telephone.
services must be received from a participating
hospice agency.                                           Expedited Decision
                                                          Blue Shield of California has established a pro-
If your condition requires services which are             cedure for our Members to request an expedited
available from the Plan, payment for services             decision (including those regarding grievances).
rendered by non-Plan providers will not be con-           A Member, physician, or representative of a
sidered unless the medical condition requires             Member may request an expedited decision
emergency or urgent services.                             when the routine decision making process might
                                                          seriously jeopardize the life or health of a Mem-
You are responsible for paying a minimum
                                                          ber, or when the Member is experiencing severe
charge (copayment) to the physician or provider
                                                          pain. Blue Shield shall make a decision and no-
of services at the time you receive services. The
                                                          tify the Member and physician as soon as possi-
specific copayments, as applicable, are listed af-
                                                          ble to accommodate the Member’s condition

                                                     18
BASIC PLAN
not to exceed 72 hours following the receipt of           For information on additional rights, see the
the request. An expedited decision may involve            Grievance Process section.
admissions, continued stay or other health care
services. If you would like additional informa-           Rates for Basic Plan
tion regarding the expedited decision process, or         State Employees and Annuitants
if you believe your particular situation qualifies        The rates shown below are effective January 1,
for an expedited decision, please contact our             2011, and will be reduced by the amount the
Member Services Department at 1-800-334-                  State of California contributes toward the cost
5847.                                                     of your health benefit plan. These contribution
                                                          amounts are subject to change as a result of col-
For all mental health and substance abuse                 lective bargaining agreements or legislative ac-
services                                                  tion. Any such change will be accomplished by
For all mental health and substance abuse ser-            the State Controller or affected retirement sys-
vices Blue Shield of California has contracted            tem without any action on your part. For cur-
with the Plan’s Mental Health Service Adminis-            rent contribution information, contact your
trator (MHSA). The MHSA should be contacted               employing agency or retirement system health
for questions about mental health and substance           benefits officer.
abuse services, MHSA Participating Providers,
or mental health and substance abuse benefits.            Cost of the Program
You may contact the MHSA at the telephone
                                                          Type of Enrollment                                Monthly Rate
number or address which appear below:
                                                          Employee only ................................................ $601.68
                1-877-263-9952                            Employee and one dependent.................... $1203.36
          Blue Shield of California                       Employee and two or more dependents .. $1564.37
     Mental Health Service Administrator
    3111 Camino Del Rio North, Suite 600
           San Diego, CA 92108
The MHSA can answer many questions over the
telephone.

The MHSA has established a procedure for our
Members to request an expedited decision. A
Member, physician, or representative of a Mem-
ber may request an expedited decision when the
routine decision making process might seriously
jeopardize the life or health of a Member, or
when the Member is experiencing severe pain.
The MHSA shall make a decision and notify the
Member and physician as soon as possible to
accommodate the Member’s condition not to
exceed 72 hours following the receipt of the re-
quest. An expedited decision may involve ad-
missions, continued stay or other health care
services. If you would like additional informa-
tion regarding the expedited decision process, or
if you believe your particular situation qualifies
for an expedited decision, please contact the
MHSA at the number listed above.




                                                     19
BASIC PLAN
Contracting Agency Employees and                                              Pricing Regions for Contracting Agency
Annuitants                                                                    Employees and Annuitants
The rates charged are based on the pricing re-                                1    San Francisco Bay Area
gion in which the employee/annuitant resides.
See below a description of the pricing regions. If                            1A   Sacramento Counties
the employee/annuitant lives outside of the
Plan’s service area and is enrolled based on                                  2    Other Northern California Counties
place of employment, then the pricing region
for the place of employment will apply. If the                                3    Los Angeles/Ventura/San Bernardino Coun-
employee/annuitant moves from one pricing                                          ties
region to another, rates will change on the first
of the month following the change of residence.
                                                                              4    Other Southern California Counties
The rates shown below are effective January 1,
2011, and will be reduced by the amount your                                  Rate Change
contracting agency contributes toward the cost                                The plan rates may be changed as of January 1,
of your health benefit plan. This amount varies                               2012, following at least 60 days’ written notice
among public agencies. For assistance on calcu-                               to the Board prior to such change.
lating your net contribution, contact your agency
or retirement system health benefits officer.

Cost of the Program
Type of Enrollment                                Monthly Rate
Employee only
  Region 1.................................................... $675.51
  Region 1A ................................................ $609.14
  Region 2.................................................... $685.67
  Region 3.................................................... $496.93
  Region 4.................................................... $567.87
Employee and one dependent
  Region 1..................................................$1351.02
  Region 1A ..............................................$1218.28
  Region 2..................................................$1371.34
  Region 3.................................................... $993.86
  Region 4..................................................$1135.74
Employee and two or more dependents
  Region 1..................................................$1756.33
  Region 1A ..............................................$1583.76
  Region 2..................................................$1782.74
  Region 3..................................................$1292.02
  Region 4..................................................$1476.46




                                                                         20
BASIC PLAN
Benefit Descriptions                                        f. Hospital ancillary services including di-
The Plan benefits available to you are listed in               agnostic laboratory, x-ray services and
this section. The copayments for these services,               therapy services;
if applicable, follow each benefit description.
                                                            g. Drugs, medications, biologicals, and
The following are the basic health care services               oxygen administered in the hospital, and
covered by the Blue Shield Access+ HMO                         up to 3 days’ supply of drugs supplied
without charge to the Member, except for co-                   upon discharge by the Plan physician for
payments where noted, and as set forth in the                  the purpose of transition from the hospi-
Third Party Recovery Process and the Member’s                  tal to home;
Responsibility section. These services are cov-
                                                            h. Surgical and anesthetic supplies, dress-
ered when medically necessary, and when pro-
                                                               ings and cast materials, surgically im-
vided by the Member’s Personal Physician or
                                                               planted devices and prostheses, other
other Plan provider or authorized as described
                                                               medical supplies and medical appliances
herein, or received according to the provisions
                                                               and equipment administered in hospital;
described under Obstetrical/Gynecological
(OB/GYN) Physician Services, Access+ Spe-                   i. Processing, storage and administration of
cialist, and Mental Health and Substance Abuse                 blood, and blood products (plasma), in
Services. Coverage for these services is subject               inpatient and outpatient settings. In-
to all terms, conditions, limitations and exclu-               cludes the storage and collection of
sions of the Agreement, to any conditions or                   autologous blood;
limitations set forth in the benefit descriptions
below, and to the Exclusions and Limitations                j. Radiation therapy, chemotherapy and re-
set forth in this booklet.                                     nal dialysis;

Except as specifically provided herein, services            k. Respiratory therapy and other diagnostic,
are covered only when rendered by an individual                therapeutic and rehabilitation services as
or entity that is licensed or certified by the state           appropriate;
to provide health care services and is operating
within the scope of that license or certification.          l. Coordinated discharge planning, includ-
                                                               ing the planning of such continuing care
A. Hospital Services                                           as may be necessary;
The following hospital services customarily fur-            m. Inpatient services, including general an-
nished by a hospital will be covered when medi-                esthesia and associated facility charges, in
cally necessary and authorized.                                connection with dental procedures when
                                                               hospitalization is required because of an
1. Inpatient hospital services include:                        underlying medical condition and clinical
                                                               status or because of the severity of the
    a. Semi-private room and board, unless a
                                                               dental procedure. Includes enrollees un-
       private room is medically necessary;
                                                               der the age of 7 and the developmentally
    b. General nursing care, and special duty                  disabled who meet these criteria. Ex-
       nursing when medically necessary;                       cludes services of dentist or oral surgeon;

    c. Meals and special diets when medically               n. Subacute care;
       necessary;
                                                            o. Medically necessary inpatient substance
    d. Intensive care services and units;                      abuse detoxification services required to
                                                               treat potentially life-threatening symp-
    e. Operating room, special treatment                       toms of acute toxicity or acute with-
       rooms, delivery room, newborn nursery                   drawal are covered when a covered
       and related facilities;                                 Member is admitted through the emer-

                                                       21
BASIC PLAN
       gency room or when medically necessary                  counseling, and OB/GYN services from an
       inpatient substance abuse detoxification                obstetrician/gynecologist or a family prac-
       is prior authorized;                                    tice physician who is within the same medi-
                                                               cal group or IPA as the Personal Physician.
    p. Rehabilitation when furnished by the                    Benefits are also provided for asthma self-
       hospital and authorized.                                management training and education to en-
                                                               able a Member to properly use asthma-
See Section O. for inpatient hospital services
                                                               related medication and equipment such as
provided under the “Hospice Program Services”
                                                               inhalers, spacers, nebulizers and peak flow
benefit.
                                                               monitors.
        Copayment: No charge.
                                                                   Copayment: $15 per visit. No addi-
                                                                   tional charge for surgery or anesthesia;
2. Outpatient hospital services include:
                                                                   radiation or renal dialysis treatments;
                                                                   medications administered in the phy-
    a. Services and supplies for treatment or                      sician’s office, including chemother-
       surgery in an outpatient hospital setting                   apy.
       or ambulatory surgery center;
                                                            2. Allergy Testing and Treatment
    b. Outpatient services, including general
       anesthesia and associated facility charges,
                                                               Office visits for the purpose of allergy test-
       in connection with dental procedures
                                                               ing and treatment, including injectables and
       when the use of a hospital or outpatient
                                                               serum.
       facility is required because of an underly-
       ing medical condition and clinical status                   Copayment: No charge.
       or because of the severity of the dental
       procedure. Includes enrollees under the              3. Inpatient Medical and Surgical Services
       age of 7 and the developmentally dis-
       abled who meet these criteria. Excludes                 Physicians’ services in a hospital or skilled
       services of dentist or oral surgeon.                    nursing facility for examination, diagnosis,
                                                               treatment, and consultation, including the
        Copayment: No charge.
                                                               services of a surgeon, assistant surgeon, an-
                                                               esthesiologist, pathologist, and radiologist.
    c. Upper and lower gastrointestinal (GI)
                                                               Inpatient physician services are covered only
       endoscopy, cataract surgery, and spinal
                                                               when hospital and skilled nursing facility
       injection.
                                                               services are also covered.
        Copayment: $250 per procedure when
        an outpatient hospital is used in lieu of                  Copayment: No charge.
        an ambulatory surgery center. This
        copayment does not apply to any en-                 4. Medically necessary home visits by Plan
        doscopy performed as a preventive                      physician
        health service.
                                                                   Copayment: $15 per visit.
B. Physician Services (Other Than for
   Mental Health and Substance Abuse                        5. Treatment of physical complications of a
                                                               mastectomy, including lymphedemas
   Services)
1. Physician Office Visits                                         Copayment: $15 per visit.
    Office visits for examination, diagnosis and            6. Internet-Based Consultations. Medically
    treatment of a medical condition, disease or               necessary consultations with Internet Ready
    injury, including specialist office visits, sec-           Physicians via Blue Shield approved Internet
    ond opinion or other consultations, diabetic

                                                       22
BASIC PLAN
    portal. Internet-based consultations are                  with Blue Shield of California medical pol-
    available only to Members whose Personal                  icy.
    Physicians (or other physicians to whom
    you have been referred for care within your           See Section F. for genetic testing for prenatal di-
    Personal Physician’s medical group or IPA)            agnosis of genetic disorders of the fetus.
    have agreed to provide Internet-based con-
    sultations via the Blue Shield approved                       Copayment: No charge.
    Internet portal (“Internet Ready”). Internet-
    based consultations for mental health and             E. Durable Medical Equipment,
    substance abuse conditions are not covered.              Prostheses and Orthoses and
    Refer to the On-Line Physician Directory to              Other Services
    determine whether your physician is Inter-            Medically necessary durable medical equipment,
    net Ready and how to initiate an Internet-            prostheses and orthoses for activities of daily
    based consultation. This information can be           living, and supplies needed to operate durable
    accessed at http://www.blueshieldca.com.              medical equipment; oxygen and oxygen equip-
                                                          ment and its administration; blood glucose
        Copayment: $10 per consultation.                  monitors as medically appropriate for insulin
                                                          dependent, non-insulin dependent and gesta-
C. Preventive Health Services                             tional diabetes; apnea monitors; and ostomy and
1. Preventive health services, as defined, when           medical supplies to support and maintain gastro-
   rendered by a physician are covered.                   intestinal, bladder or respiratory function are
                                                          covered. When authorized as durable medical
2. Eye refraction to determine the need for               equipment, other covered items include peak
   corrective lenses for all Members upon re-             flow monitor for self-management of asthma,
   ferral by the Personal Physician. (Limited to          the glucose monitor for self-management of
   one visit per calendar year, for Members               diabetes, apnea monitors for management of
   aged 18 and over. No limit on number of                newborn apnea, and the home prothrombin
   visits for Members under age 18.)                      monitor for specific conditions as determined
                                                          by Blue Shield. Benefits are provided at the
        Copayment: No charge.                             most cost-effective level of care that is consis-
                                                          tent with professionally recognized standard of
D. Diagnostic X-ray/Lab Services                          practice. If there are two or more professionally
1. X-ray, Laboratory, Major Diagnostic Ser-               recognized items equally appropriate for a con-
   vices. All outpatient diagnostic x-ray and             dition, benefits will be based on the most cost-
   clinical laboratory tests and services, includ-        effective item.
   ing diagnostic imaging, electrocardiograms,
   diagnostic clinical isotope services, bone             1. Durable Medical Equipment
   mass measurements, and periodic blood
   lipid screening.                                           a. Replacement of durable medical equip-
                                                                 ment is covered only when it no longer
2. Genetic Testing and Diagnostic Procedures.                    meets the clinical needs of the patient or
   Genetic testing for certain conditions when                   has exceeded the expected lifetime of the
   the Member has risk factors such as family                    item.*
   history or specific symptoms. The testing
   must be expected to lead to increased or al-                  *This does not apply to the medically
   tered monitoring for early detection of dis-                  necessary replacement of nebulizers, face
   ease, a treatment plan or other therapeutic                   masks and tubing, and peak flow moni-
   intervention and determined to be medically                   tors for the management and treatment
   necessary and appropriate in accordance                       of asthma. (See Section P. for benefits
                                                                 for asthma inhalers and inhaler spacers.)



                                                     23
BASIC PLAN
   b. Medically necessary repairs and mainte-                  6) Cochlear implants;
      nance of durable medical equipment, as
      authorized by Plan provider. Repair is                   7) Contact lenses if medically necessary
      covered unless necessitated by misuse or                    to treat eye conditions such as kerato-
      loss.                                                       conus, keratitis sicca or aphakia. Cata-
                                                                  ract spectacles or intraocular lenses
   c. Rental charges for durable medical                          that replace the natural lens of the eye
      equipment in excess of the purchase                         after cataract surgery. If medically
      price are not covered.                                      necessary with the insertion of the in-
                                                                  traocular lens, one pair of conven-
   d. Benefits do not include environmental                       tional eyeglasses or contact lenses;
      control equipment or generators. No
      benefits are provided for backup or al-                  8) Artificial limbs and eyes.
      ternate items.
                                                            b. Routine maintenance is not covered.
See Section V. for devices, equipment and sup-
plies for the management and treatment of dia-              c. Benefits do not include wigs for any rea-
betes.                                                         son, self-help/educational devices or any
                                                               type of speech or language assistance de-
If you are enrolled in a hospice program                       vices, except as specifically provided
through a participating hospice agency, medical                above. See the Exclusions and Limita-
equipment and supplies that are reasonable and                 tions section for a listing of excluded
necessary for the palliation and management of                 speech and language assistance devices.
terminal illness and related conditions are pro-               No benefits are provided for backup or
vided by the hospice agency. For information                   alternate items.
see Section O.
                                                            For surgically implanted and other pros-
2. Prostheses                                               thetic devices (including prosthetic bras)
                                                            provided to restore and achieve symmetry
   a. Medically necessary prostheses for activi-            incident to a mastectomy, see Section W.
      ties of daily living, including the follow-           Surgically implanted prostheses including,
      ing:                                                  but not limited to, Blom-Singer and artificial
                                                            larynx prostheses for speech following a
       1) Supplies necessary for the operation              laryngectomy are covered as a surgical pro-
          of prostheses;                                    fessional benefit.
       2) Initial fitting and replacement after          3. Orthoses
          the expected life of the item;
                                                            a. Medically necessary orthoses for activi-
       3) Repairs, even if due to damage;                      ties of daily living, including the follow-
                                                               ing:
       4) Surgically implanted prostheses in-
          cluding, but not limited to, Blom-                   1) Special footwear required for foot
          Singer and artificial larynx prostheses                 disfigurement which includes but is
          for speech following a laryngectomy;                    not limited to foot disfigurement
                                                                  from cerebral palsy, arthritis, polio,
       5) Prosthetic devices used to restore a
                                                                  spina bifida, diabetes or by accident
          method of speaking following laryn-
                                                                  or developmental disability;
          gectomy, including initial and subse-
          quent prosthetic devices and                         2) Medically necessary functional foot
          installation accessories. This does not                 orthoses that are custom made rigid
          include electronic voice producing                      inserts for shoes, ordered by a physi-
          machines;                                               cian or podiatrist, and used to treat

                                                    24
BASIC PLAN
          mechanical problems of the foot, an-                See Section D. for information on coverage
          kle or leg by preventing abnormal                   of other genetic testing and diagnostic pro-
          motion and positioning when im-                     cedures.
          provement has not occurred with a
          trial of strapping or an over-the-                      Copayment: No charge.
          counter stabilizing device;
                                                          2. Inpatient Hospital and Professional Ser-
       3) Medically necessary knee braces for                vices. Hospital and Professional services for
          post-operative rehabilitation follow-              the purposes of a normal delivery, C-
          ing ligament surgery, instability due to           section, complications or medical conditions
          injury, and to reduce pain and insta-              arising from pregnancy or resulting child-
          bility for patients with osteoarthritis.           birth.
   b. Benefits for medically necessary orthoses                   Copayment: No charge.
      are provided at the most cost-effective
      level of care that is consistent with pro-          3. Includes providing coverage for all testing
      fessionally recognized standards of prac-              recommended by the California Newborn
      tice. If there are two or more                         Screening Program and for participating in
      professionally recognized appliances                   the statewide prenatal testing program, ad-
      equally appropriate for a condition, the               ministered by the State Department of
      Plan will provide benefits based on the                Health Services, known as the Expanded
      most cost-effective appliance. Routine                 Alpha Feto Protein Program.
      maintenance is not covered. No benefits
      are provided for backup or alternate                        Copayment: No charge.
      items.
                                                          The Newborns' and Mothers' Health Protection
   c. Benefits are provided for orthotic de-              Act requires group health plans to provide a
      vices for maintaining normal activities of          minimum hospital stay for the mother and new-
      daily living only. No benefits are pro-             born child of 48 hours after a normal, vaginal
      vided for orthotic devices such as knee             delivery and 96 hours after a C-section unless
      braces intended to provide additional               the attending physician, in consultation with the
      support for recreational or sports activi-          mother, determines a shorter hospital length of
      ties or for orthopedic shoes and other              stay is adequate.
      supportive devices for the feet.
                                                          If the hospital stay is less than 48 hours after a
       Copayment: No charge.                              normal, vaginal delivery or less than 96 hours af-
                                                          ter a C-section, a follow-up visit for the mother
See Section V. for devices, equipment and sup-            and newborn within 48 hours of discharge is
plies for the management and treatment of dia-            covered when prescribed by the treating physi-
betes.                                                    cian. This visit shall be provided by a licensed
                                                          health care provider whose scope of practice in-
F. Pregnancy and Maternity Care                           cludes postpartum and newborn care. The treat-
The following pregnancy and maternity care is             ing physician, in consultation with the mother,
covered subject to the General Exclusions and             shall determine whether this visit shall occur at
Limitations.                                              home, the contracted facility, or the physician’s
                                                          office.
1. Prenatal and Postnatal Physician Office Vis-
   its                                                    G. Family Planning and Infertility
                                                             Services
                                                          1. Family Planning Counseling

                                                                  Copayment: No charge.

                                                     25
BASIC PLAN
2. Infertility Services. Infertility services (in-           only if a reasonable person would have be-
   cluding artificial insemination), except as ex-           lieved that the medical condition was an
   cluded in the General Exclusions and                      emergency medical condition which re-
   Limitations, including professional, hospital,            quired ambulance services, as described in
   ambulatory surgery center, ancillary services             Section I.
   and injectable drugs administered or pre-
   scribed by the provider to diagnose and                2. Non-Emergency Ambulance Services
   treat the cause of infertility.
                                                             Medically necessary ambulance services to
        Copayment: 50% of allowed charges                    transfer the Member from a non-Plan hos-
        for all services.                                    pital to a Plan hospital, between Plan facili-
                                                             ties, or from facility to home when in
3. Sterilization Procedures, including Tubal                 connection with authorized confinement/
   Ligation and Vasectomy                                    admission and the use of the ambulance is
                                                             authorized.
        Copayment: See applicable copay-
        ments for Physician Services and Hos-                    Copayment: No charge.
        pital Services.
                                                          I. Emergency Services
4. Elective Abortion                                      An emergency means an unexpected medical
                                                          condition manifesting itself by acute symptoms
        Copayment: See applicable copay-
                                                          of sufficient severity (including severe pain)
        ments for Physician Services and Hos-
                                                          such that a layperson who possesses an average
        pital Services.
                                                          knowledge of health and medicine could rea-
5. Contraceptive Devices and Fitting                      sonably assume that the absence of immediate
                                                          medical attention could be expected to result in
        Copayment: $15 per visit; $5 per device           any of the following: (1) placing the Member’s
        in conjunction with office visit. Dia-            health in serious jeopardy, (2) serious impair-
        phragms also covered under Section                ment to bodily functions, (3) serious dysfunc-
        P.; see applicable copayments for Pre-            tion of any bodily organ or part. If you receive
        scription Drugs.                                  services in a situation that the Blue Shield Ac-
                                                          cess+ HMO determines was not a situation in
6. Oral, Transdermal Patch, and Vaginal Ring              which a reasonable person would believe that an
   Contraceptives                                         emergency condition existed, you will be re-
                                                          sponsible for the costs of those services.
        Copayment: See applicable copay-
        ments for Prescription Drugs.                     1. Members who reasonably believe that they
                                                             have an emergency medical or mental health
7. Injectable Contraceptives, excluding inter-               condition which requires an emergency re-
   nally implanted time release contraceptives               sponse are encouraged to appropriately use
                                                             the “911” emergency response system
        Copayment: $15 per visit; $15 for each               where available. The Member should notify
        injection.                                           the Personal Physician or the MHSA by
                                                             phone within 24 hours of the commence-
H. Ambulance Services                                        ment of the emergency services, or as soon
The Plan will pay for ambulance services as fol-             as it is medically possible for the Member to
lows:                                                        provide notice. Failure to provide notice as
                                                             stated will result in the services not being
1. Emergency Ambulance Services                              covered.
    For transportation to the nearest hospital
    which can provide such emergency care

                                                     26
BASIC PLAN
2. Whenever possible, go to the emergency                  tact Blue Shield at the telephone number on
   room of your nearest Blue Shield Access+                your identification card.
   HMO hospital for medical emergencies. A
   listing of Blue Shield Access+ HMO hospi-            5. Claims for Emergency and Out-of-Area Ur-
   tals is available in your HMO Physician and             gent Services. Contact Member Services to
   Hospital Directory.                                     obtain a claim form.

3. The services will be reviewed retrospectively           a. Emergency. If emergency services were
   by the Plan to determine whether the ser-                  received and expenses were incurred by
   vices were for a medical condition for which               the Member, for services other than
   a reasonable person would have believed                    medical transportation, the Member
   that they had an emergency medical condi-                  must submit a complete claim with the
   tion.                                                      emergency service record for payment to
                                                              the Plan, within 1 year after the first pro-
       Copayment: $50 per visit in the hospi-                 vision of emergency services for which
       tal emergency room. (Emergency ser-                    payment is requested. If the claim is not
       vices copayment does not apply if                      submitted within this period, the Plan
       Member is admitted directly to hospi-                  will not pay for those emergency ser-
       tal as an inpatient from emergency                     vices, unless the claim was submitted as
       room or kept for observation and hos-                  soon as reasonably possible as deter-
       pital bills for an emergency room ob-                  mined by the Plan. If the services are not
       servation visit.)                                      pre-authorized, the Plan will review the
                                                              claim retrospectively for coverage. If the
4. Continuing or Follow-up Treatment. If you
                                                              Plan determines that these services re-
   receive emergency services from a hospital
                                                              ceived were for a medical condition for
   which is a non-Plan hospital, follow-up care
                                                              which a reasonable person would not
   must be authorized by Blue Shield or it may
                                                              reasonably believe that an emergency
   not be covered. If, once your emergency
                                                              condition existed and would not other-
   medical condition is stabilized, and your
                                                              wise have been authorized, and, there-
   treating health care provider at the non-Plan
                                                              fore, are not covered, it will notify the
   hospital believes that you require additional
                                                              Member of that determination. The Plan
   medically necessary hospital services, the
                                                              will notify the Member of its determina-
   non-Plan hospital must contact Blue Shield
                                                              tion within 30 days from receipt of the
   to obtain timely authorization. Blue Shield
                                                              claim. In the event covered medical
   may authorize continued medically neces-
                                                              transportation services are obtained in
   sary hospital services by the non-Plan hospi-
                                                              such an emergency situation, the Blue
   tal. If Blue Shield determines that you may
                                                              Shield Access+ HMO shall pay the
   be safely transferred to a hospital that is
                                                              medical transportation provider directly.
   contracted with the Plan and you refuse to
   consent to the transfer, the non-Plan hospi-            b. Out-of-Area Urgent Services. If out-of-
   tal must provide you with written notice                   area urgent services were received from a
   that you will be financially responsible for               non-participating BlueCard Program
   100% of the cost for services provided to                  provider, you must submit a complete
   you once your emergency condition is sta-                  claim with the urgent service record for
   ble. Also, if the non-Plan hospital is unable              payment to the Plan, within 1 year after
   to determine the contact information at                    the first provision of urgent services for
   Blue Shield in order to request prior au-                  which payment is requested. If the claim
   thorization, the non-Plan hospital may bill                is not submitted within this period, the
   you for such services. If you believe you are              Plan will not pay for those urgent ser-
   improperly billed for services you receive                 vices, unless the claim was submitted as
   from a non-Plan hospital, you should con-                  soon as reasonably possible as deter-


                                                   27
BASIC PLAN
       mined by the Plan. The services will be                provider whenever possible, but you may
       reviewed retrospectively by the Plan to                also receive care from a non-participating
       determine whether the services were ur-                BlueCard Program provider. If you received
       gent services. If the Plan determines that             services from a non-Blue Shield provider,
       the services would not have been author-               you must submit a claim to Blue Shield for
       ized, and therefore, are not covered, it               payment. The services will be reviewed ret-
       will notify the Member of that determi-                rospectively by the Plan to determine
       nation. The Plan will notify the Member                whether the services were urgent services.
       of its determination within 30 days from               See Section I.5. Claims for Emergency and
       receipt of the claim.                                  Out-of-Area Urgent Services for additional
                                                              information.
J. Urgent Services
Urgent services are provided in response to the               Up to two medically necessary out-of-area
patient’s need for a prompt diagnostic workup                 follow-up care outpatient visits are covered.
and/or treatment.                                             Authorization by Blue Shield is required for
                                                              more than two follow-up outpatient visits or
These services are applicable for a medical or                for care that involves a surgical or other
mental disorder that: (1) could become an                     procedure or inpatient stay. Blue Shield may
emergency if not diagnosed and/or treated in a                direct the Member to receive the additional
timely manner, (2) is likely to result in prolonged           follow-up care from the Personal Physician.
temporary impairment, (3) could increase the
risk of necessitating more complex or hazardous            3. When outside the United States, Members
treatment, and (4) could develop in a chronic                 may call the BlueCard Worldwide Network
illness or inordinate physical or psychological               at 1-804-673-1177. Urgent services are avail-
suffering of the patient.                                     able through the BlueCard Worldwide Net-
                                                              work, but may be received from any
1. When within California, but outside of your                provider.
   Personal Physician service area, if possible
   contact Blue Shield Member Services at                     Before traveling abroad, Members should
   1-800-334-5847 for assistance in receiving                 call their local Member Services office for
   urgent services. Member Services will assist               the most current listing of participating pro-
   Members in receiving urgent services                       viders worldwide or they can go on-line at
   through a Blue Shield of California Plan                   http://www.bcbs.com and select the “Find
   provider. Members may also locate a Plan                   a Doctor or Hospital” tab. However, a
   provider by visiting Blue Shield’s internet site           Member is not required to receive urgent
   at http://www.blueshieldca.com. You are                    services outside of the United States from
   not required to use a Blue Shield of Califor-              the BlueCard Worldwide Network. If the
   nia Plan provider to receive urgent services;              Member does not use the BlueCard World-
   you may use any provider. However, the                     wide Network, a claim must be submitted as
   services will be reviewed retrospectively by               described in Section I.5. Claims for Emer-
   the Plan to determine whether the services                 gency and Out-of-Area Urgent Services.
   were urgent services.
                                                           4. To receive urgent care within your Personal
2. When temporarily traveling within the                      Physician service area, call your Personal
   United States, call the 24-hour toll-free                  Physician’s office or follow instructions
   number 1-800-810-BLUE (2583) to obtain                     given by your assigned medical group or
   information about the nearest BlueCard                     IPA in accordance with all the conditions of
   Program participating provider. When a                     the Agreement.
   BlueCard Program participating provider is
   available, you should obtain out-of-area ur-                   Copayment: $15 per visit.
   gent or follow-up care from a participating


                                                      28
BASIC PLAN
K. Home Health Care Services,                              See Section O. for information about when a
   PKU-Related Formulas and                                Member is admitted into a hospice program and
   Special Food Products, and                              a specialized description of skilled nursing ser-
   Home Infusion Therapy                                   vices for hospice care.
1. Home Health Care Services
                                                           For information concerning diabetes self-
   Benefits are provided for home health care              management training, see Section V.
   services when the services are medically
                                                           2. PKU-Related Formulas and Special Food
   necessary, ordered by the Personal Physician
                                                              Products
   and authorized.
                                                               Benefits are provided for enteral formulas,
   a. Home visits to provide skilled nursing
                                                               related medical supplies and special food
      services and other skilled services by any
                                                               products that are medically necessary for the
      of the following professional providers
                                                               treatment of phenylketonuria (PKU) to
      are covered:
                                                               avert the development of serious physical or
      1) Registered nurse;                                     mental disabilities or to promote normal de-
                                                               velopment or function as a consequence of
      2) Licensed vocational nurse;                            PKU. These benefits must be prior author-
                                                               ized and must be prescribed or ordered by
      3) Certified home health aide in con-                    the appropriate health care professional.
         junction with the services of 1) or 2),
         above;                                                    Copayment: No charge.
      4) Medical Social Worker.                            3. Home Infusion/Home Injectable Therapy
                                                              Provided by a Home Infusion Agency
       Copayment: No charge.
                                                               Benefits are provided for home infusion and
      5) Physical     therapist,   occupational
                                                               intravenous (IV) injectable therapy when
         therapist, or speech therapist.
                                                               provided by a home infusion agency. Note:
       Copayment: $15 per visit for therapy                    For services related to hemophilia, see item
       provided in the home.                                   4. below.

   b. In conjunction with the professional ser-                Services include home infusion agency
      vices rendered by a home health agency,                  skilled nursing services, parenteral nutrition
      medical supplies used during a covered                   services and associated supplements, medi-
      visit by the home health agency neces-                   cal supplies used during a covered visit,
      sary for the home health care treatment                  pharmaceuticals administered intravenously,
      plan, and related laboratory services to                 related laboratory services and for medically
      the extent the benefit would have been                   necessary, FDA approved injectable medica-
      provided had the Member remained in                      tions, when prescribed by the Personal Phy-
      the hospital or skilled nursing facility, ex-            sician and prior authorized, and when
      cept as excluded in the General Exclu-                   provided by a home infusion agency.
      sions and Limitations.
                                                               This benefit does not include medications,
       Copayment: No charge.                                   drugs, insulin, insulin syringes, specialty
                                                               drugs covered under Section P., and services
This benefit does not include medications,                     related to hemophilia which are covered as
drugs, or injectables covered under Section K.                 described below.
or P.
                                                                   Copayment: No charge.


                                                      29
BASIC PLAN
Skilled Nursing Services are defined as a level of             elsewhere in this Benefit Descriptions sec-
care that includes services that can only be per-              tion.
formed safely and correctly by a licensed nurse
(either a registered nurse or a licensed vocational            This benefit does not include:
nurse).
                                                               a. Physical therapy, gene therapy or medi-
4. Hemophilia Home Infusion Products and                          cations including antifibrinolytic and
   Services                                                       hormone medications*;

    Benefits are provided for home infusion                    b. Services from a hemophilia treatment
    products for the treatment of hemophilia                      center or any provider not prior author-
    and other bleeding disorders. All services                    ized by the Plan; or,
    must be prior authorized by the Plan and
                                                               c. Self-infusion training programs, other
    must be provided by a preferred Hemo-
                                                                  than nursing visits to assist in administra-
    philia Infusion Provider. (Note: Most par-
                                                                  tion of the product.
    ticipating home health care and home
    infusion agencies are not preferred Hemo-                  *Services and certain drugs may be covered
    philia Infusion Providers.) To find a pre-                 under Section L., Section P., or as described
    ferred Hemophilia Infusion Provider,                       elsewhere in this Benefit Descriptions sec-
    consult the Preferred Provider Directory.                  tion.
    You may also verify this information by call-
    ing Member Services at the telephone num-                      Copayment: $15 per visit.
    ber shown on the back cover of this
    booklet.                                               L. Physical and Occupational Therapy
                                                           Rehabilitation services include physical therapy,
    Hemophilia Infusion Providers offer 24-                occupational therapy, and/or respiratory therapy
    hour service and provide prompt home de-               pursuant to a written treatment plan and when
    livery of hemophilia infusion products.                rendered in the provider’s office or outpatient
                                                           department of a hospital. Benefits for speech
    Following evaluation by your physician, a              therapy are described in Section M. Medically
    prescription for a blood factor product must           necessary services will be authorized for an ini-
    be submitted to and approved by the Plan.              tial treatment period and any additional subse-
    Once prior authorized by the Plan, the                 quent medically necessary treatment periods if
    blood factor product is covered on a regu-             after conducting a review of the initial and each
    larly scheduled basis (routine prophylaxis) or         additional subsequent period of care, it is de-
    when a non-emergency injury or bleeding                termined that continued treatment is medically
    episode occurs. (Emergencies will be cov-              necessary and is provided with the expectation
    ered as described in Section I.)                       that the patient has restorative potential.
    Included in this benefit is the blood factor                   Copayment: No charge for inpatient
    product for in-home infusion use by the                        therapy. $15 per visit for therapy pro-
    Member, necessary supplies such as ports                       vided in the home or other outpatient
    and syringes, and necessary nursing visits.                    setting.
    Services for the treatment of hemophilia
    outside the home, except for services in in-           See Section K. for information on coverage for
    fusion suites managed by a preferred He-               rehabilitation services rendered in the home.
    mophilia Infusion Provider, and medically
    necessary services to treat complications of           M. Speech Therapy
    hemophilia replacement therapy are not                 Outpatient benefits for speech therapy services
    covered under this benefit but may be cov-             when diagnosed and ordered by a physician and
    ered under other medical benefits described            provided by an appropriately licensed speech

                                                      30
BASIC PLAN
therapist, pursuant to a written treatment plan            ing facility and authorized. This benefit is lim-
for an appropriate time to: (1) correct or im-             ited to 100 days during any calendar year except
prove the speech abnormality, or (2) evaluate              when received through a hospice program pro-
the effectiveness of treatment, and when ren-              vided by a participating hospice agency. Custo-
dered in the provider’s office or outpatient de-           dial care is not covered.
partment of a hospital.
                                                           For information concerning “Hospice Program
Services are provided for the correction of, or            Services” see Section O.
clinically significant improvement of, speech
abnormalities that are the likely result of a diag-                Copayment: No charge.
nosed and identifiable medical condition, illness,
or injury to the nervous system or to the vocal,           O. Hospice Program Services
swallowing, or auditory organs.                            Benefits are provided for the following services
                                                           through a participating hospice agency when an
Continued outpatient benefits will be provided             eligible Member requests admission to and is
for medically necessary services as long as con-           formally admitted to an approved hospice pro-
tinued treatment is medically necessary, pursu-            gram. The Member must have a terminal illness
ant to the treatment plan, and likely to result in         as determined by his Plan provider’s certifica-
clinically significant progress as measured by ob-         tion and the admission must receive prior ap-
jective and standardized tests. The provider’s             proval from Blue Shield. (Note: Members with
treatment plan and records will be reviewed pe-            a terminal illness who have not elected to enroll
riodically. When continued treatment is not                in a hospice program can receive a pre-hospice
medically necessary pursuant to the treatment              consultative visit from a participating hospice
plan, not likely to result in additional clinically        agency.) Covered services are available on a 24-
significant improvement, or no longer requires             hour basis to the extent necessary to meet the
skilled services of a licensed speech therapist,           needs of individuals for care that is reasonable
the Member will be notified of this determina-             and necessary for the palliation and manage-
tion and benefits will not be provided for ser-            ment of terminal illness and related conditions.
vices rendered after the date of written                   Members can continue to receive covered ser-
notification.                                              vices that are not related to the palliation and
                                                           management of the terminal illness from the
Except as specified above and as stated under              appropriate Plan provider. Member copayments
Section K., no outpatient benefits are provided            when applicable are paid to the participating
for speech therapy, speech correction, or speech           hospice agency.
pathology services.
                                                           Note: Hospice services provided by a non-
        Copayment: No charge for inpatient                 participating hospice agency are not covered ex-
        therapy. $15 per visit for therapy pro-            cept in certain circumstances in counties in Cali-
        vided in the home or other outpatient              fornia in which there are no participating
        setting.                                           hospice agencies. If Blue Shield prior authorizes
                                                           hospice program services from a non-contracted
See Section K. for information on coverage for             hospice, the Member’s copayment for these ser-
speech therapy services rendered in the home.              vices will be the same as the copayments for
See Section A. for information on inpatient                hospice program services when received and au-
benefits and Section O. for hospice program                thorized by a participating hospice agency.
services.
                                                           All of the services listed below must be received
N. Skilled Nursing Facility Services                       through the participating hospice agency.
Subject to all of the inpatient hospital services
provisions under Section A., medically necessary           1. Pre-hospice consultative visit regarding pain
skilled nursing services, including subacute care,            and symptom management, hospice and
will be covered when provided in a skilled nurs-

                                                      31
BASIC PLAN
    other care options including care planning                 tinuous basis during periods of crisis but the
    (Members do not have to be enrolled in the                 care provided during these periods must be
    hospice program to receive this benefit).                  predominantly nursing care.

2. Interdisciplinary Team care with develop-               12. Respite care services are limited to an occa-
   ment and maintenance of an appropriate                      sional basis and to no more than 5 consecu-
   plan of care and management of terminal                     tive days at a time.
   illness and related conditions.
                                                           Members are allowed to change their participat-
3. Skilled nursing services, certified health aide         ing hospice agency only once during each period
   services and homemaker services under the               of care. Members can receive care for two 90-
   supervision of a qualified registered nurse.            day periods followed by an unlimited number of
                                                           60-day periods. The care continues through an-
4. Bereavement services.                                   other period of care if the Plan provider recerti-
                                                           fies that the Member is terminally ill.
5. Social services/counseling services with
   medical social services provided by a quali-            Definitions
   fied social worker. Dietary counseling, by a            Bereavement Services - services available to
   qualified provider, shall also be provided              the immediate surviving family members for a
   when needed.                                            period of at least 1 year after the death of the
                                                           Member. These services shall include an assess-
6. Medical direction with the medical director             ment of the needs of the bereaved family and
   being also responsible for meeting the gen-             the development of a care plan that meets these
   eral medical needs for the terminal illness of          needs, both prior to, and following the death of
   the Members to the extent that these needs              the Member.
   are not met by the Personal Physician.
                                                           Continuous Home Care - home care provided
7. Volunteer services.                                     during a period of crisis. A minimum of 8 hours
                                                           of continuous care, during a 24-hour day, be-
8. Short-term inpatient care arrangements.                 ginning and ending at midnight is required. This
                                                           care could be 4 hours in the morning and an-
9. Pharmaceuticals, medical equipment and
                                                           other 4 hours in the evening. Nursing care must
   supplies that are reasonable and necessary
                                                           be provided for more than half of the period of
   for the palliation and management of termi-
                                                           care and must be provided by either a registered
   nal illness and related conditions.
                                                           nurse or licensed practical nurse. Homemaker
                                                           services or home health aide services may be
10. Physical therapy, occupational therapy, and
                                                           provided to supplement the nursing care. When
    speech-language pathology services for pur-
                                                           fewer than 8 hours of nursing care are required,
    poses of symptom control, or to enable the
                                                           the services are covered as routine home care
    enrollee to maintain activities of daily living
                                                           rather than continuous home care.
    and basic functional skills.
                                                           Home Health Aide Services - services provid-
11. Nursing care services are covered on a con-
                                                           ing for the personal care of the terminally ill
    tinuous basis for as much as 24 hours a day
                                                           Member and the performance of related tasks in
    during periods of crisis as necessary to
                                                           the Member’s home in accordance with the plan
    maintain a Member at home. Hospitaliza-
                                                           of care in order to increase the level of comfort
    tion is covered when the Interdisciplinary
                                                           and to maintain personal hygiene and a safe,
    Team makes the determination that skilled
                                                           healthy environment for the patient. Home
    nursing care is required at a level that cannot
                                                           health aide services shall be provided by a per-
    be provided in the home. Either home-
                                                           son who is certified by the California Depart-
    maker services or home health aide services
                                                           ment of Health Services as a home health aide
    or both may be covered on a 24-hour con-

                                                      32
BASIC PLAN
pursuant to Chapter 8 of Division 2 of the                  6. Actively utilizes volunteers in the delivery of
Health and Safety Code.                                        hospice services.

Homemaker Services - services that assist in                7. Provides services in the Member’s home or
the maintenance of a safe and healthy environ-                 primary place of residence to the extent ap-
ment and services to enable the Member to                      propriate based on the medical needs of the
carry out the treatment plan.                                  Member.

Hospice Service or Hospice Program - a                      8. Is provided through a participating hospice
specialized form of interdisciplinary health care              agency.
that is designed to provide palliative care, allevi-
ate the physical, emotional, social and spiritual           Interdisciplinary Team - the hospice care
discomforts of a Member who is experiencing                 team that includes, but is not limited to, the
the last phases of life due to the existence of a           Member and the Member’s family, a physician
terminal disease, to provide supportive care to             and surgeon, a registered nurse, a social worker,
the primary caregiver and the family of the hos-            a volunteer, and a spiritual caregiver.
pice patient, and which meets all of the follow-
ing criteria:                                               Medical Direction - services provided by a li-
                                                            censed physician and surgeon who is charged
1. Considers the Member and the Member’s                    with the responsibility of acting as a consultant
   family in addition to the Member, as the                 to the Interdisciplinary Team, a consultant to
   unit of care.                                            the Member’s Personal Physician, as requested,
                                                            with regard to pain and symptom management,
2. Utilizes an Interdisciplinary Team to assess             and liaison with physicians and surgeons in the
   the physical, medical, psychological, social             community. For purposes of this section, the
   and spiritual needs of the Member and the                person providing these services shall be referred
   Member’s family.                                         to as the “medical director”.

3. Requires the Interdisciplinary Team to de-               Period of Care - the time when the Personal
   velop an overall plan of care and to provide             Physician recertifies that the Member still needs
   coordinated care which emphasizes suppor-                and remains eligible for hospice care even if the
   tive services, including, but not limited to,            Member lives longer than 1 year. A period of
   home care, pain control, and short-term in-              care starts the day the Member begins to receive
   patient services. Short-term inpatient ser-              hospice care and ends when the 90 or 60-day
   vices are intended to ensure both continuity             period has ended.
   of care and appropriateness of services for
   those Members who cannot be managed at                   Period of Crisis - a period in which the Mem-
   home because of acute complications or the               ber requires continuous care to achieve pallia-
   temporary absence of a capable primary                   tion or management of acute medical
   caregiver.                                               symptoms.

4. Provides for the palliative medical treatment            Plan of Care - a written plan developed by the
   of pain and other symptoms associated with               attending physician and surgeon, the “medical
   a terminal disease, but does not provide for             director” (as defined under “Medical Direc-
   efforts to cure the disease.                             tion”) or physician and surgeon designee, and
                                                            the Interdisciplinary Team that addresses the
5. Provides for bereavement services following              needs of a Member and family admitted to the
   the Member’s death to assist the family to               hospice program. The hospice shall retain over-
   cope with social and emotional needs asso-               all responsibility for the development and main-
   ciated with the death of the Member.                     tenance of the plan of care and quality of
                                                            services delivered.


                                                       33
BASIC PLAN
Respite Care Services - short-term inpatient                 P. Prescription Drugs
care provided to the Member only when neces-                 Except for the calendar year maximum copayments and
sary to relieve the family members or other per-             the Coordination of Benefits provision, the general provi-
sons caring for the Member.                                  sions and exclusions of the HMO Health Plan Agree-
                                                             ment shall apply.
Skilled Nursing Services - nursing services
provided by or under the supervision of a regis-             This plan's prescription drug coverage is on average
tered nurse under a plan of care developed by                equivalent to or better than the standard benefit set by
the Interdisciplinary Team and the Member’s                  the federal government for Medicare Part D (also called
Plan provider to a Member and his family that                creditable coverage). Because this Plan’s prescription drug
pertain to the palliative, supportive services re-           coverage is creditable, you do not have to enroll in Medi-
quired by a Member with a terminal illness.                  care Part D while you maintain this coverage; however,
Skilled nursing services include, but are not lim-           you should be aware that if you have a subsequent break
ited to, Member assessment, evaluation and case              in this coverage of 63 days or more before enrolling in
management of the medical nursing needs of                   Medicare Part D you could be subject to payment of
the Member, the performance of prescribed                    higher Part D premiums.
medical treatment for pain and symptom con-
trol, the provision of emotional support to both             Benefits are provided for outpatient prescription
the Member and his family, and the instruction               drugs which meet all of the requirements speci-
of caregivers in providing personal care to the              fied in this section, are prescribed by a physician
enrollee. Skilled nursing services provide for the           or other licensed health care provider within the
continuity of services for the Member and his                scope of his or her license as long as the pre-
family and are available on a 24-hour on-call ba-            scriber is a Plan provider, are obtained from a
sis.                                                         participating pharmacy, and are listed in the
                                                             Drug Formulary. Drug coverage is based on the
Social Service/Counseling Services - those                   use of Blue Shield’s Outpatient Drug Formulary,
counseling and spiritual services that assist the            which is updated on an ongoing basis by Blue
Member and his family to minimize stresses and               Shield's Pharmacy and Therapeutics Committee.
problems that arise from social, economic, psy-              Non-Formulary drugs may be covered subject
chological, or spiritual needs by utilizing appro-           to higher copayments. Select drugs and drug
priate community resources, and maximize                     dosages and most specialty drugs require prior
positive aspects and opportunities for growth.               authorization by Blue Shield for medical neces-
                                                             sity, appropriateness of therapy or when effec-
Terminal Disease or Terminal Illness - a                     tive, lower cost alternatives are available.
medical condition resulting in a prognosis of life           Prescription smoking cessation drugs are cov-
of 1 year or less, if the disease follows its natural        ered for Members. See Section Y. for more in-
course.                                                      formation about smoking cessation.
Volunteer Services - services provided by                    Outpatient Drug Formulary
trained hospice volunteers who have agreed to                Medications are selected for inclusion in Blue
provide service under the direction of a hospice             Shield’s Outpatient Drug Formulary based on
staff member who has been designated by the                  safety, efficacy, FDA bioequivalency data and
hospice to provide direction to hospice volun-               then cost. New drugs and clinical data are re-
teers. Hospice volunteers may provide support                viewed regularly to update the Formulary. Drugs
and companionship to the Member and his fam-                 considered for inclusion or exclusion from the
ily during the remaining days of the Member’s                Formulary are reviewed by Blue Shield’s Phar-
life and to the surviving family following the               macy and Therapeutics Committee during
Member’s death.                                              scheduled meetings four times a year.
        Copayment: No charge.
                                                             Members may call Blue Shield Member Services
                                                             at the number listed on their Blue Shield identi-

                                                        34
BASIC PLAN
fication card to inquire if a specific drug is in-        brand name drug, (2) contain the same active
cluded in the Formulary. Member Services can              ingredient as the brand name drug, and (3) cost
also provide Members with a printed copy of               less than the brand name drug equivalent.
the Formulary. Members may also access the
Formulary through the Blue Shield of California           Maintenance Drugs - covered outpatient pre-
Web site at http://www.blueshieldca.com.                  scription drugs prescribed to treat chronic or
                                                          long-term conditions including conditions such
Benefits may be provided for non-Formulary                as diabetes, asthma, hypertension and chronic
drugs subject to higher copayments.                       heart disease.

Definitions                                               Non-Formulary Drugs - drugs determined by
Brand Name Drugs - drugs which are FDA                    Blue Shield's Pharmacy and Therapeutics Com-
approved either (1) after a new drug application,         mittee as being duplicative or as having pre-
or (2) after an abbreviated new drug application          ferred Formulary drug alternatives available.
and which has the same brand name as that of              Benefits may be provided for non-Formulary
the manufacturer with the original FDA ap-                drugs and are always subject to the non-
proval.                                                   Formulary copayment.

Drugs - (1) drugs which are approved by the               Non-Participating Pharmacy - a pharmacy
Food and Drug Administration (FDA), requir-               which does not participate in the Blue Shield
ing a prescription either by federal or California        Pharmacy Network.
law, (2) insulin, and disposable hypodermic insu-
lin needles and syringes, (3) pen delivery systems        Participating Pharmacy - a pharmacy which
for the administration of insulin as determined           participates in the Blue Shield Pharmacy Net-
by Blue Shield to be medically necessary,                 work. These participating pharmacies have
(4) diabetic testing supplies (including lancets,         agreed to a contracted rate for covered prescrip-
lancet puncture devices, and blood and ketone             tions for Blue Shield Members.
urine testing strips and test tablets in medically
appropriate quantities for the monitoring and             To select a participating pharmacy, the Member
treatment of insulin dependent, non-insulin de-           may go to http://www.blueshieldca.com or call
pendent and gestational diabetes), (5) oral,              Member Services at 1-800-334-5847.
transdermal patch, and vaginal ring contracep-
tives and diaphragms, and (6) inhalers and in-            Specialty Drugs - specialty drugs are specific
haler spacers for the management and treatment            drugs used to treat complex or chronic condi-
of asthma. Note: No prescription is necessary             tions which usually require close monitoring
to purchase the items shown in (2), (3) and (4);          such as multiple sclerosis, hepatitis, rheumatoid
however, in order to be covered these items               arthritis, cancer, and other conditions that are
must be ordered by your provider.                         difficult to treat with traditional therapies. Spe-
                                                          cialty drugs are listed in Blue Shield’s Outpatient
Formulary - a comprehensive list of drugs                 Drug Formulary. Specialty drugs may be self-
maintained by Blue Shield's Pharmacy and                  administered in the home by injection by the pa-
Therapeutics Committee for use under the Blue             tient or family member (subcutaneously or in-
Shield Prescription Drug Program, which is de-            tramuscularly), by inhalation, orally or topically.
signed to assist physicians in prescribing drugs          Infused or IV medications are not included as
that are medically necessary and cost effective.          specialty drugs. These drugs may also require
The Formulary is updated periodically. If not             special handling, may require special manufac-
otherwise excluded, the Formulary includes all            turing processes, and may have limited prescrib-
generic drugs.                                            ing or limited pharmacy availability. Specialty
                                                          drugs must be considered safe for self-
Generic Drugs - drugs that (1) are approved by            administration by Blue Shield’s Pharmacy and
the FDA as a therapeutic equivalent to the                Therapeutics Committee, must be obtained
                                                          from a Blue Shield specialty pharmacy and may

                                                     35
BASIC PLAN
require prior authorization for medical necessity        If the participating pharmacy contracted rate
by Blue Shield.                                          charged by the participating pharmacy is less
                                                         than or equal to the Member copayment, the
Specialty Pharmacy Network - select partici-             Member will only be required to pay the partici-
pating pharmacies contracted by Blue Shield to           pating pharmacy contracted rate.
provide covered specialty drugs. These pharma-
cies offer 24-hour clinical services and provide         Prescription drugs administered in a physician’s
prompt home delivery of specialty drugs.                 office, except immunizations, are covered by the
                                                         $15 copayment for the office visit and do not
To select a specialty pharmacy, the Member may           require another copayment.
go to http://www.blueshieldca.com or call
Member Services at 1-800-334-5847.                       Some prescriptions are limited to a maximum al-
                                                         lowable quantity based on medical necessity and
Obtaining Outpatient Prescription                        appropriateness of therapy as determined by
Drugs at a Participating Pharmacy                        Blue Shield’s Pharmacy and Therapeutics
To obtain drugs at a participating pharmacy, the         Committee.
Member must present his Blue Shield identifica-
tion card. Note: Except for covered emergen-             If the Member requests a brand name drug
cies, claims for drugs obtained without using the        when a generic drug equivalent is available, the
identification card will be denied.                      Member is responsible for paying the difference
                                                         between the participating pharmacy contracted
Benefits are provided for specialty drugs only           rate for the brand name drug and its generic
when obtained from a Blue Shield specialty               drug equivalent, as well as the applicable generic
pharmacy, except in the case of an emergency.            drug copayment.
In the event of an emergency, covered specialty
drugs that are needed immediately may be ob-             If the prescription specifies a brand name drug
tained from any participating pharmacy, or, if           and the prescribing provider has written “Dis-
necessary from a non-participating pharmacy.             pense As Written” or “Do Not Substitute” on
                                                         the prescription, or if a generic drug equivalent
        Copayment: $30 per prescription for a            is not available, the Member is responsible for
        30-day supply.                                   paying the applicable brand name drug copay-
                                                         ment.
The Member is responsible for paying the appli-
cable copayment for each covered new and refill          You may request a reduced copayment for the
prescription drug. The pharmacist will collect           non-Formulary brand name medication through
from the Member the applicable copayment at              Blue Shield’s prior authorization process by ob-
the time the drugs are obtained.                         taining a statement from your provider that
                                                         clearly attests to the necessity for the non-
        Copayment: $5 generic, $15 brand                 Formulary product versus the preferred Formu-
        name*, $45 non-Formulary, 50% of the             lary product or available generic alternative. See
        Blue Shield contracted rate for drugs            the section below on Prior Authorization Proc-
        for erectile dysfunction per prescrip-           ess for Select Formulary, Non-Formulary, and
        tion for the amount prescribed not to            Specialty Drugs for information on the approval
        exceed a 30-day supply; after 3                  process. If the request is approved, the reduced
        months, the copayment for Mainte-                non-Formulary brand name medication copay-
        nance drugs is $10 generic, $25 brand            ment will be $40 per 30-day prescription at a re-
        name, $75 non-Formulary per pre-                 tail pharmacy, and you will be charged the
        scription for each subsequent 30-day
                                                         reduced non-Formulary brand name medication
        supply.
                                                         copayment for that specific non-preferred prod-
*For diaphragms, the Formulary brand name                uct for 1 year from the date of approval. If you
copayment applies.                                       wish to continue to receive the reduced copay-


                                                    36
BASIC PLAN
ment at the end of the 1-year approval period,           Obtaining Outpatient Prescription
you will need to make a new request using the            Drugs Through the Mail Service
process noted above. To avoid paying an in-              Prescription Drug Program
creased copayment, it is suggested that you              For the Member’s convenience, when drugs
submit your new request 30 days prior to the             have been prescribed for a chronic condition
expiration of the previous approval. Failure to          and the Member's medication dosage has been
attest to a supportable medical need for a non-          stabilized, he may obtain the drug through Blue
Formulary brand name medication will result in           Shield's Mail Service Prescription Drug Pro-
denial of the reduced copayment request and              gram. The Member may continue to obtain the
your non-Formulary copayment will apply. This            drug from a participating pharmacy; however,
does not apply to drugs for erectile dysfunction.        after 3 months, the higher Maintenance drug
                                                         copayment will apply for each subsequent 30-
When Maintenance drugs have been prescribed              day supply. Blue Shield will provide mail order
for a chronic condition and the Member’s medi-           forms and information at the time of enroll-
cation dosage has been stabilized and he has re-         ment. The Member’s provider must indicate a
ceived the same medication and dosage through            prescription quantity which is equal to the
the Blue Shield Pharmacy Network for 3                   amount to be dispensed. Note: This does not
months, he may obtain the drug through the               apply to specialty drugs, nor to any other drugs
Mail Service Prescription Drug Program. If the           which are not available through or cannot safely
Member continues to obtain the drug from a               be obtained through the Mail Service Prescrip-
participating pharmacy, the higher Maintenance           tion Drug Program.
drug copayment will apply for each subsequent
30-day supply. Note: This does not apply to              The Member is responsible for paying the appli-
specialty drugs, nor to any other drugs which are        cable copayment for each covered new and refill
not available through or cannot safely be ob-            prescription drug. Copayments will be tracked
tained through the Mail Service Prescription             for the Member.
Drug Program. This also does not apply to
Maintenance drugs for which a lower copay-                       Copayment: $10 generic, $25 brand
ment was approved pursuant to the paragraph                      name, $75 non-Formulary per pre-
above.                                                           scription not to exceed a 90-day sup-
                                                                 ply; $1,000 out-of-pocket annual
Drugs obtained at a non-participating pharmacy                   maximum, then no charge excluding
are not covered, unless medically necessary for a                non-Formulary drugs. If the Member’s
covered emergency, including drugs for emer-                     provider indicates a prescription quan-
gency contraception. If the Member must obtain                   tity of less than a 90-day supply, that
drugs from a non-participating pharmacy due to                   amount will be dispensed and refill au-
an emergency, the submission of a Prescription                   thorizations cannot be combined to
Drug Claim is required. Claim forms are avail-                   reach a 90-day supply.
able by contacting Member Services. Submit
completed Prescription Drug Claim form noting            If the participating pharmacy contracted rate is
"Emergency Request" on form to Blue Shield               less than or equal to the Member copayment,
Pharmacy Services, P.O. Box 7168, San Fran-              the Member will only be required to pay the par-
cisco, CA 94120. Claims must be received                 ticipating pharmacy contracted rate.
within 1 year from the date of service to be con-
sidered for payment. Reimbursement for cov-              If the Member requests a mail service brand
ered emergency claims will be based upon the             name drug when a mail service generic drug
purchase price of covered prescription drug(s)           equivalent is available, the Member is responsi-
less any applicable copayment(s).                        ble for the difference between the contracted
                                                         rate for the mail service brand name drug and its
                                                         mail service generic drug equivalent, as well as
                                                         the applicable mail service generic drug copay-
                                                         ment.

                                                    37
BASIC PLAN
If the prescription specifies a mail service brand        Prior Authorization Process for
name drug and the prescribing provider has                Select Formulary, Non-Formulary, and
written “Dispense As Written” or “Do Not                  Specialty Drugs
Substitute” on the prescription, or if a mail ser-        Select Formulary drugs, as well as most specialty
vice generic drug equivalent is not available, the        drugs may require prior authorization for medi-
Member is responsible for paying the applicable           cal necessity. Select non-Formulary drugs may
mail service brand name drug copayment.                   require prior authorization for medical necessity,
                                                          and to determine if lower cost alternatives are
You may request a reduced copayment for the               available and just as effective. Your physician
non-Formulary brand name medication through               may request prior authorization by submitting
Blue Shield’s prior authorization process by ob-          supporting information to Blue Shield. Once all
taining a statement from your provider that               required supporting information is received,
clearly attests to the necessity for the non-             prior authorization approval or denial, based
Formulary product versus the preferred Formu-             upon medical necessity, is provided within 5
lary product or available generic alternative. See        business days or within 72 hours for an expe-
the section below on Prior Authorization Proc-            dited review.
ess for Select Formulary, Non-Formulary, and
Specialty Drugs for information on the approval           Exclusions
process. If the request is approved, the reduced
                                                          No benefits are provided under the Prescription
non-Formulary brand name medication copay-
                                                          Drugs benefit for the following (please note,
ment will be $70 for up to a 90-day supply pre-
                                                          certain services excluded below may be covered
scription at the mail service pharmacy, and you
                                                          under other benefits/portions of this Evidence
will be charged the reduced non-Formulary
                                                          of Coverage – you should refer to the applicable
brand name medication copayment for that spe-
                                                          section to determine if drugs are covered under
cific non-preferred product for 1 year from the
                                                          that benefit):
date of approval. If you wish to continue to re-
ceive the reduced copayment at the end of the             1. Drugs obtained from a non-participating
1-year approval period, you will need to make a              pharmacy, except for a covered emergency,
new request using the process noted above. To                drugs for emergency contraception, and
avoid paying an increased copayment, it is sug-              drugs obtained outside of California which
gested that you submit your new request 30 days              are related to an urgently needed service and
prior to the expiration of the previous approval.            for which a participating pharmacy was not
Failure to attest to a supportable medical need              reasonably accessible;
for a non-Formulary brand name medication
will result in denial of the reduced copayment            2. Any drug provided or administered while
request and your non-Formulary copayment will                the Member is an inpatient, or in a pro-
apply. This does not apply to drugs for erectile             vider's office (see A. Hospital Services and
dysfunction.                                                 B. Physician Services);
For information about the Mail Service Pre-               3. Take home drugs received from a hospital,
scription Drug Program, the Member may refer                 convalescent home, skilled nursing facility,
to the mail service program brochure for the                 or similar facility (see A. Hospital Services
phone number and a more detailed explanation                 and N. Skilled Nursing Facility Services);
or call Blue Shield Member Services at 1-800-
334-5847. The TTY telephone number is 1-866-              4. Drugs except as specifically listed as covered
346-7197.                                                    under this Section P., which can be obtained
                                                             without a prescription or for which there is
                                                             a non-prescription drug that is the identical
                                                             chemical equivalent (i.e., same active ingre-
                                                             dient and dosage) to a prescription drug;


                                                     38
BASIC PLAN
5. Drugs for which the Member is not legally                   antibiotics prescribed to treat infection nor
   obligated to pay, or for which no charge is                 to medications prescribed to treat pain;
   made;
                                                           16. Drugs packaged in convenience kits that in-
6. Drugs that are considered to be experimen-                  clude non-prescription convenience items,
   tal or investigational;                                     unless the drug is not otherwise available
                                                               without the non-prescription components.
7. Medical devices or supplies, except as spe-                 This exclusion shall not apply to items used
   cifically listed as covered herein (see E. Du-              for the administration of diabetes or asthma
   rable Medical Equipment, Prostheses and                     drugs.
   Orthoses and Other Services). This exclu-
   sion also includes topically applied prescrip-          Call Member Services at 1-800-334-5847 for fur-
   tion preparations that are approved by the              ther information.
   FDA as medical devices;
                                                           See the Grievance Process section of this Evi-
8. Drugs when prescribed for cosmetic pur-                 dence of Coverage for information on filing a
   poses, including but not limited to drugs               grievance, your right to seek assistance from the
   used to retard or reverse the effects of skin           Department of Managed Health Care and your
   aging or to treat hair loss;                            rights to independent medical review.

9. Dietary or nutritional products (see K.                 Q. Inpatient Mental Health and
   Home Health Care Services, PKU-Related                     Substance Abuse Services
   Formulas and Special Food Products, and                 Blue Shield of California’s MHSA administers
   Home Infusion Therapy);                                 and delivers the Plan’s mental health and sub-
                                                           stance abuse benefits. These services are pro-
10. Injectable drugs which are not self-                   vided through a unique network of MHSA
    administered. Other injectable medications             Participating Providers. All non-emergency
    may be covered under Y. Additional Ser-                mental health and substance abuse services must
    vices;                                                 be arranged through the MHSA. Also, all non-
                                                           emergency mental health and substance abuse
11. Appetite suppressants or drugs for body                services must be prior authorized by the MHSA.
    weight reduction except when medically                 For prior authorization for mental health and
    necessary for the treatment of morbid obe-             substance abuse services, Members should con-
    sity. In such cases the drug will be subject to        tact the MHSA at 1-866-505-3409.
    prior authorization from Blue Shield;
                                                           All non-emergency mental health and substance
12. Drugs when prescribed for smoking cessa-               abuse services must be obtained from MHSA
    tion purposes, except as provided under this           Participating Providers. (See the How to Use the
    Section P.;                                            Plan section, the Mental Health and Substance
                                                           Abuse Services paragraphs for more informa-
13. Compounded medications if: (1) there is a
                                                           tion.)
    medically appropriate Formulary alternative,
    or, (2) there are no FDA-approved indica-              Benefits are provided for the following medi-
    tions. Compounded medications that do not              cally necessary covered mental health conditions
    include at least one drug, as defined, are not         and substance abuse conditions, subject to ap-
    covered;                                               plicable copayments and charges in excess of
                                                           any benefit maximums. Coverage for these ser-
14. Replacement of lost, stolen or destroyed
                                                           vices is subject to all terms, conditions, limita-
    prescription drugs;
                                                           tions and exclusions of the Agreement, to any
                                                           conditions or limitations set forth in the benefit
15. Drugs prescribed for treatment of dental
    conditions. This exclusion shall not apply to

                                                      39
BASIC PLAN
description below, and to the Exclusions and              2. The treatment of damage to natural teeth
Limitations set forth in this booklet.                       caused solely by an accidental injury is lim-
                                                             ited to medically necessary services until the
Benefits are provided for inpatient hospital and             services result in initial, palliative stabiliza-
professional services in connection with hospi-              tion of the Member as determined by the
talization for the treatment of mental health                Plan;
conditions and substance abuse conditions. All
non-emergency mental health and substance                     Dental services provided after initial medical
abuse services must be prior authorized by the                stabilization, prosthodontics, orthodontia
MHSA and obtained from MHSA Participating                     and cosmetic services are not covered. This
Providers. Residential care is not covered.                   benefit does not include damage to the
                                                              natural teeth that is not accidental (e.g., re-
See Section A. for information on medically                   sulting from chewing or biting).
necessary inpatient substance abuse detoxifica-
tion.                                                     3. Medically necessary non-surgical treatment
                                                             (e.g., splint and physical therapy) of Tem-
        Copayment: No charge.                                poromandibular Joint Syndrome (TMJ);

R. Outpatient Mental Health and                           4. Surgical and arthroscopic treatment of TMJ
   Substance Abuse Services                                  if prior history shows conservative medical
1. Benefits are provided for outpatient facility             treatment has failed;
   and office visits for mental health condi-
   tions and substance abuse conditions.                  5. Medically necessary treatment of maxilla and
                                                             mandible (jaw joints and jaw bones);
        Copayment: $15 per visit.
                                                          6. Orthognathic surgery (surgery to reposition
2. Benefits are provided for hospital and pro-               the upper and/or lower jaw) which is medi-
   fessional services in connection with partial             cally necessary to correct skeletal deformity;
   hospitalization for the treatment of mental               or
   health conditions and substance abuse con-
   ditions.                                               7. Dental and orthodontic services that are an
                                                             integral part of reconstructive surgery for
        Copayment: No charge.                                cleft palate repair.

3. Psychosocial Support through LifeReferrals                     Copayment: See applicable copay-
   24/7                                                           ments for Physician Services and Hos-
                                                                  pital Services.
    See the Mental Health and Substance Abuse
    Services paragraphs under the How to Use              This benefit does not include:
    the Plan section for information on psycho-
    social support services.                              1. Services performed on the teeth, gums
                                                             (other than for tumors and dental and or-
        Copayment: No charge.                                thodontic services that are an integral part
                                                             of reconstructive surgery for cleft palate re-
S. Medical Treatment of the Teeth,                           pair) and associated periodontal structures,
   Gums, Jaw Joints or Jaw Bones                             routine care of teeth and gums, diagnostic
Hospital and professional services provided for              services, preventive or periodontic services,
conditions of the teeth, gums or jaw joints and              dental orthosis and prosthesis, including
jaw bones, including adjacent tissues are a bene-            hospitalization incident thereto;
fit only to the extent that they are provided for:
                                                          2. Orthodontia (dental services to correct ir-
1. The treatment of tumors of the gums;                      regularities or malocclusion of the teeth) for

                                                     40
BASIC PLAN
    any reason (except for orthodontic services           Transplant Network Facility is covered subject
    that are an integral part of reconstructive           to prior authorization. In general, more than
    surgery for cleft palate repair), including           one evaluation (including tests) within a short
    treatment to alleviate TMJ;                           time period and/or more than one Transplant
                                                          Network Facility will not be authorized unless
3. Any procedure (e.g., vestibuloplasty) in-              the medical necessity of repeating the service is
   tended to prepare the mouth for dentures or            documented and approved. For information on
   for the more comfortable use of dentures;              Blue Shield of California’s approved Transplant
                                                          Network, call 1-800-334-5847.
4. Dental implants (endosteal, subperiosteal or
   transosteal);                                          The following procedures are eligible for cover-
                                                          age under this provision:
5. Alveolar ridge surgery of the jaws if per-
   formed primarily to treat diseases related to          1. Human heart transplants;
   the teeth, gums or periodontal structures or
   to support natural or prosthetic teeth;                2. Human lung transplants;

6. Fluoride treatments except when used with              3. Human heart and lung transplants in com-
   radiation therapy to the oral cavity.                     bination;

See the Exclusions and Limitations section for            4. Human liver transplants;
additional services that are not covered.
                                                          5. Human kidney and pancreas transplants in
T. Special Transplant Benefits                               combination (kidney only transplants are
Benefits are provided for certain procedures                 covered under Section U.);
listed below only if: (1) performed at a Trans-
plant Network Facility approved by Blue Shield            6. Human bone marrow transplants, including
of California to provide the procedure, (2) prior            autologous bone marrow transplantation or
authorization is obtained, in writing, from the              autologous peripheral stem cell transplanta-
Blue Shield Corporate Medical Director, and                  tion used to support high-dose chemother-
(3) the recipient of the transplant is a Member.             apy when such treatment is medically
                                                             necessary and is not experimental or investi-
The Blue Shield Corporate Medical Director                   gational;
shall review all requests for prior authorization
and shall approve or deny benefits, based on the          7. Pediatric human small bowel transplants;
medical circumstances of the patient, and in ac-
cordance with established Blue Shield medical             8. Pediatric and adult human small bowel and
policy. Failure to obtain prior written authoriza-           liver transplants in combination.
tion as described above and/or failure to have
the procedure performed at a Blue Shield ap-              Reasonable charges for services incident to ob-
proved Transplant Network Facility will result            taining the transplanted material from a living
in denial of claims for this benefit.                     donor or an organ transplant bank will be cov-
                                                          ered.
Pre-transplant evaluation and diagnostic tests,
transplantation and follow-ups will be allowed                    Copayment: Physician Services and
                                                                  Hospital Services copayments apply.
only at a Blue Shield approved Transplant Net-
work       Facility. Non-acute/non-emergency
                                                          U. Organ Transplant Benefits
evaluations, transplantations and follow-ups at
facilities other than a Blue Shield Transplant            Hospital and professional services provided in
Network Facility will not be approved. Evalua-            connection with human organ transplants are a
tion of potential candidates at a Blue Shield             benefit to the extent that they are provided in
                                                          connection with the transplant of a cornea, kid-

                                                     41
BASIC PLAN
ney, or skin, and the recipient of such transplant            cian and authorized. These benefits shall in-
is a Member.                                                  clude, but not be limited to, instruction that
                                                              will enable diabetic patients and their fami-
Services incident to obtaining the human organ                lies to gain an understanding of the diabetic
transplant material from a living donor or an or-             disease process, and the daily management
gan transplant bank will be covered.                          of diabetic therapy, in order to thereby
                                                              avoid frequent hospitalizations and compli-
        Copayment: Physician Services and                     cations.
        Hospital Services copayments apply.
                                                                  Copayment: $15 per visit.
V. Diabetes Care
1. Diabetic Equipment                                     W. Reconstructive Surgery
                                                          Medically necessary services in connection with
    Benefits are provided for the following de-           reconstructive surgery when there is no other
    vices and equipment, including replacement            more appropriate covered surgical procedure,
    after the expected life of the item and when          and with regards to appearance, when recon-
    medically necessary, for the management               structive surgery offers more than a minimal
    and treatment of diabetes when medically              improvement in appearance (including congeni-
    necessary and authorized:                             tal anomalies) are covered. In accordance with
                                                          the Women’s Health & Cancer Rights Act, sur-
    a. blood glucose monitors, including those            gically implanted and other prosthetic devices
       designed to assist the visually impaired;          (including prosthetic bras) and reconstructive
                                                          surgery on either breast to restore and achieve
    b. insulin pumps and all related necessary
                                                          symmetry incident to a mastectomy, and treat-
       supplies;
                                                          ment of physical complications of a mastec-
    c. podiatric devices to prevent or treat dia-         tomy, including lymphedemas, are covered.
       betes-related complications, including ex-         Surgery must be authorized as described herein.
       tra-depth orthopedic shoes;                        Benefits will be provided in accordance with
                                                          guidelines established by the Plan and developed
    d. visual aids, excluding eyewear and/or              in conjunction with plastic and reconstructive
       video-assisted devices, designed to assist         surgeons.
       the visually impaired with proper dosing
       of insulin;                                        No benefits will be provided for the following
                                                          surgeries or procedures unless for reconstructive
    e. for coverage of diabetic testing supplies          surgery:
       including blood and urine testing strips
       and test tablets, lancets and lancet punc-         1. Surgery to excise, enlarge, reduce, or change
       ture devices and pen delivery systems for             the appearance of any part of the body;
       the administration of insulin, see Section
       P.                                                 2. Surgery to reform or reshape skin or bone;

        Copayment: No charge.                             3. Surgery to excise or reduce skin or connec-
                                                             tive tissue that is loose, wrinkled, sagging, or
2. Diabetes Self-Management Training                         excessive on any part of the body;
    Diabetes outpatient self-management train-            4. Hair transplantation; and
    ing, education and medical nutrition therapy
    that is medically necessary to enable a               5. Upper eyelid blepharoplasty without docu-
    Member to properly use the diabetes-related              mented significant visual impairment or
    devices and equipment and any additional                 symptomatology.
    treatment for these services if directed or
    prescribed by the Member’s Personal Physi-

                                                     42
BASIC PLAN
This limitation shall not apply to breast recon-            4. Services that, except for the fact that they
struction when performed subsequent to a mas-                  are being provided in a clinical trial, are spe-
tectomy, including surgery on either breast to                 cifically excluded under the Plan;
achieve or restore symmetry.
                                                            5. Services customarily provided by the re-
        Copayment: Physician Services and                      search sponsor free of charge for any enrol-
        Hospital Services copayments apply.                    lee in the trial.

X. Clinical Trials for Cancer                               An approved clinical trial is limited to a trial that
Benefits are provided for routine patient care              is:
for a Member whose Personal Physician has ob-
tained prior authorization and who has been ac-             1. Approved by one of the following:
cepted into an approved clinical trial for cancer
provided that:                                                  a. one of the National Institutes of Health;

1. The clinical trial has a therapeutic intent and              b. the federal Food and Drug Administra-
   the Member’s treating physician determines                      tion, in the form of an investigational
   that participation in the clinical trial has a                  new drug application;
   meaningful potential to benefit the Member;                  c. the United States Department of De-
   with a therapeutic intent; and                                  fense;
2. The Member’s treating physician recom-                       d. the United States Veterans’ Administra-
   mends participation in the clinical trial; and                  tion; or
3. The hospital and/or physician conducting                 2. Involves a drug that is exempt under federal
   the clinical trial is a Plan provider, unless the           regulations from a new drug application.
   protocol for the trial is not available through
   a Plan provider.                                                 Copayment: Physician Services and
                                                                    Hospital Services copayments apply.
Services for routine patient care will be paid on
the same basis and at the same benefit levels as            Y. Additional Services
other covered services.                                     1. Personal Health Management Program

Routine patient care consists of those services                 Health education and health promotion ser-
that would otherwise be covered by the Plan if                  vices provided by Blue Shield’s Center for
those services were not provided in connection                  Health Improvement offer a variety of well-
with an approved clinical trial, but does not in-               ness resources including, but not limited to:
clude:                                                          a member newsletter and a prenatal health
                                                                education program.
1. Drugs or devices that have not been ap-
   proved by the federal Food and Drug Ad-                          Copayment: No charge.
   ministration (FDA);
                                                            2. Injectable Medications
2. Services other than health care services,
   such as travel, housing, companion expenses                  Injectable medications approved by the
   and other non-clinical expenses;                             FDA are covered for the medically neces-
                                                                sary treatment of medical conditions when
3. Any item or service that is provided solely                  prescribed or authorized by the Personal
   to satisfy data collection and analysis needs                Physician or as described herein. See Section
   and that is not used in the clinical manage-
   ment of the patient;


                                                       43
BASIC PLAN
   P. for information on insulin and specialty                 Excludes the purchase of batteries or
   drugs coverage and copayment.                               other ancillary equipment, except those
                                                               covered under the terms of the initial
       Copayment: No charge.                                   hearing aid purchase and charges for a
                                                               hearing aid which exceed specifications
3. Away From Home Care® Program                                prescribed for correction of a hearing
                                                               loss. Excludes replacement parts for
   The Blue Shield Access+ HMO offers to                       hearing aids, repair of hearing aid after
   CalPERS members who are long-term trav-                     the covered 1-year warranty period and
   elers, students and families living apart,                  replacement of a hearing aid more than
   Away From Home Care (AFHC).                                 once in any period of 36 months. Also
                                                               excludes surgically implanted hearing de-
   AFHC offers full HMO benefits with a local                  vices. Cochlear implants are not consid-
   ID card. Membership eligibility is applicable               ered surgically implanted hearing devices
   to spouses, domestic partners and depend-                   and are covered as a prosthetic under
   ents who are away from home for at least 90                 Section E.
   days, or to members who are away from
   home for at least 90 days but not more than                 Limitations: Up to maximum of $1,000
   180 days. There is no additional charge to                  per Member every 36 months for both
   the member. AFHC is coordinated by call-                    ears for the hearing aid instrument,
   ing 1-800-334-5847.                                         and ancillary equipment.

   AFHC also offers a special short-term ser-              To receive these services, you may either
   vice which is available to members requiring            contact your Personal Physician to obtain a
   specific follow-up treatment. This option is            referral or self-refer to an Access+ Specialist
   particularly beneficial for members who will            as described in the How to Use the Plan
   be out-of-state on a short-term basis but re-           section.
   quire special treatment.
                                                        5. Smoking Cessation
4. Hearing Aid Services
                                                           Members who participate and complete a
   a. Audiological Evaluation. To measure the              smoking cessation class or program will be
      extent of hearing loss and a hearing aid             reimbursed up to $100 per class or program
      evaluation to determine the most appro-              per calendar year. Members may contact
      priate make and model of hearing aid.                their medical group or IPA for information
                                                           about these classes and programs. If you
       Copayment: No charge. Evaluation is                 have a question about the smoking cessation
       in addition to the $1,000 maximum al-               benefit, you should call Blue Shield Member
       lowed every 36 months for both ears                 Services at 1-800-334-5847.
       for the hearing aid and ancillary
       equipment.                                       Member Maximum Calendar Year
   b. Hearing Aid. Monaural or binaural in-
                                                        Copayment
      cluding ear mold(s), the hearing aid in-          The Member maximum calendar year copay-
      strument, the initial battery, cords and          ment responsibility for covered services exclud-
      other ancillary equipment. Includes visits        ing those specified, is listed in the Summary of
      for fitting, counseling, adjustments, re-         Covered Services. (Also, see the Member Maxi-
      pairs, etc. at no charge for a 1-year pe-         mum Calendar Year Copayment paragraphs un-
      riod following the provision of a covered         der How to Use the Plan.)
      hearing aid.
                                                        Note that copayments and charges for services
                                                        not accruing to the Member maximum calendar
                                                        year copayment continue to be the Member’s

                                                   44
BASIC PLAN
responsibility after the calendar year copayment              vices and supplies for treatment of the teeth
maximum is reached.                                           and gums (except for tumors and dental and
                                                              orthodontic services that are an integral part
Exclusions and Limitations                                    of reconstructive surgery for cleft palate
General Exclusions and Limitations                            procedures) and associated periodontal
Unless exceptions to the following exclusions                 structures, including but not limited to diag-
are specifically made elsewhere in the Agree-                 nostic, preventive, orthodontic, and other
ment, no benefits are provided for services                   services such as dental cleaning, tooth whit-
which are:                                                    ening, x-rays, topical fluoride treatment ex-
                                                              cept when used with radiation therapy to the
1. Acupuncture. For or incident to acupunc-                   oral cavity, fillings and root canal treatment;
   ture;                                                      treatment of periodontal disease or perio-
                                                              dontal surgery for inflammatory conditions;
2. Behavioral Problems. For learning dis-                     tooth extraction; dental implants; braces,
   abilities, behavioral problems or social skills            crowns, dental orthoses and prostheses; ex-
   training/therapy;                                          cept as specifically provided under A. and
                                                              S.;
3. Cosmetic Surgery. For cosmetic surgery,
   or any resulting complications, except medi-           6. Experimental or Investigational Procedures.
   cally necessary services to treat complica-               Experimental or investigational medicine,
   tions of cosmetic surgery (e.g., infections or            surgery or other experimental or investiga-
   hemorrhages) will be a benefit, but only                  tional health care procedures as defined, ex-
   upon review and approval by a Blue Shield                 cept for services for Members who have
   physician consultant. Without limiting the                been accepted into an approved clinical trial
   foregoing, no benefits will be provided for               for cancer as provided under X.;
   the following surgeries or procedures:
                                                              See section entitled “External Independent
    • Lower eyelid blepharoplasty;                            Medical Review” for information concern-
    • Spider veins;                                           ing the availability of a review of services
    • Services and procedures to smooth the                   denied under this exclusion.
      skin (e.g., chemical face peels, laser re-
      surfacing, and abrasive procedures);                7. Eye Surgery. For surgery to correct refrac-
    • Hair removal by electrolysis or other                  tive error (such as but not limited to radial
      means; and                                             keratotomy, refractive keratoplasty), lenses
                                                             and frames for eyeglasses, contact lenses,
    • Reimplantation of breast implants
                                                             except as provided under E., and video-
      originally provided for cosmetic aug-
                                                             assisted visual aids or video magnification
      mentation;
                                                             equipment for any purpose;
4. Custodial or Domiciliary Care. For or in-
                                                          8. Foot Care. For routine foot care, including
   cident to services rendered in the home or
                                                             callus, corn paring or excision and toenail
   hospitalization or confinement in a health
                                                             trimming (except as may be provided
   facility primarily for custodial, maintenance,
                                                             through a participating hospice agency);
   domiciliary care or residential care, except as
                                                             treatment (other than surgery) of chronic
   provided under O.; or rest;
                                                             conditions of the foot, including but not
5. Dental Care, Dental Appliances. For den-                  limited to weak or fallen arches, flat or pro-
   tal care or services incident to the treatment,           nated foot, pain or cramp of the foot, bun-
   prevention or relief of pain or dysfunction               ions, muscle trauma due to exertion or any
   of the temporomandibular joint and/or                     type of massage procedure on the foot; spe-
   muscles of mastication, except as specifically            cial footwear (e.g., non-custom made or
   provided under S.; for or incident to ser-                over-the-counter shoe inserts or arch sup-


                                                     45
BASIC PLAN
    ports), except as specifically provided under           16. Miscellaneous Equipment. For orthope-
    E. and V.;                                                  dic shoes except for therapeutic footwear
                                                                for diabetics and except as provided under
9. Genetic Testing. For genetic testing except                  V., environmental control equipment, gen-
   as described under D. and F.;                                erators, exercise equipment, self-help/
                                                                educational devices, vitamins, any type of
10. Home Monitoring Equipment. For home                         communicator, voice enhancer, voice pros-
    testing devices and monitoring equipment,                   thesis, electronic voice producing machine,
    except as specifically provided under E.;                   or any other language assistance devices, ex-
                                                                cept as provided under E. and comfort
11. Infertility Reversal. For or incident to the                items;
    treatment of infertility or any form of as-
    sisted reproductive technology, including               17. Nutritional and Food Supplements. For
    but not limited to the reversal of a vasec-                 prescription or non-prescription nutritional
    tomy or tubal ligation, or any resulting com-               and food supplements except as provided
    plications, except for medically necessary                  under K., and except as provided through a
    treatment of medical complications;                         hospice agency;
12. Infertility Services. For any services related          18. Organ Transplants. Incident to an organ
    to assisted reproductive technology, includ-                transplant, except as provided under T. and
    ing but not limited to the harvesting or                    U.;
    stimulation of the human ovum, ovum
    transplants, in vitro fertilization, Gamete In-         19. Over-the-Counter Medical Equipment
    trafallopian Transfer (GIFT) procedure, Zy-                 or Supplies. For non-prescription (over-
    gote Intrafallopian Transfer (ZIFT)                         the-counter) medical equipment or supplies
    procedure or any other form of induced fer-                 that can be purchased without a licensed
    tilization (except for artificial insemination),            provider's prescription order, even if a li-
    services or medications to treat low sperm                  censed provider writes a prescription order
    count or services incident to or resulting                  for a non-prescription item, except as spe-
    from procedures for a surrogate mother                      cifically provided under E., K., O. and V.;
    who is otherwise not eligible for covered
    pregnancy and maternity care under a Blue               20. Over-the-Counter Medications. For over-
    Shield of California health plan;                           the-counter medications not requiring a pre-
                                                                scription, except as provided for smoking
13. Learning Disabilities. For testing for in-                  cessation drugs;
    telligence or learning disabilities;
                                                            21. Pain Management. For or incident to
14. Limited or Excluded Services. Benefits                      hospitalization or confinement in a pain
    for services limited or excluded in your                    management center to treat or cure chronic
    HMO health service plan; however, drugs                     pain, except as may be provided through a
    customarily provided by dentists and oral                   participating hospice agency and except as
    surgeons, or customarily provided for nerv-                 medically necessary;
    ous or mental disorders, or incident to
    pregnancy, or customarily provided for sub-             22. Penile Implant. For penile implant devices
    stance abuse, or incident to physical therapy               and surgery, and any related services except
    are not excluded;                                           for any resulting complications and medi-
                                                                cally necessary services as provided under
15. Mental Health. For any services relating to                 W.;
    the diagnosis or treatment of any mental or
    emotional illness or disorder that is not a             23. Personal Comfort Items. Convenience
    mental health condition;                                    items such as telephones, TVs, guest trays,
                                                                and personal hygiene items;

                                                       46
BASIC PLAN
24. Physical Examinations. For physical ex-                   • Upper eyelid blepharoplasty without
    ams required for licensure, employment, or                  documented significant visual impair-
    insurance unless the examination corre-                     ment or symptomatology;
    sponds to the schedule of routine physical
    examinations provided under C.;                           This limitation shall not apply to breast re-
                                                              construction when performed subsequent to
25. Prescription Orders. Prescription orders                  a mastectomy, including surgery on either
    or refills which exceed the amount specified              breast to achieve or restore symmetry.
    in the prescription, or prescription orders or
    refills dispensed more than a year from the           29. Services by Close Relatives. Services per-
    date of the original prescription.                        formed by a close relative or by a person
                                                              who ordinarily resides in the Member’s
    Prescription orders or refills in quantities              home;
    exceeding a 30-day supply, except for mail
    order.                                                30. Sex Transformations. For transgender or
                                                              gender dysphoria conditions, including but
    Prescription orders or refills which are equal            not limited to, intersex surgery (transsexual
    to or less than the amount of your copay-                 operations), or any related services, or any
    ment.                                                     resulting medical complications, except for
                                                              treatment of medical complications that is
26. Private Duty Nursing. In connection with                  medically necessary;
    private duty nursing, except as provided un-
    der A., K. and O.;                                    31. Sexual Dysfunctions. For or incident to
                                                              sexual dysfunctions and sexual inadequacies,
27. Reading/Vocational Therapy. For or in-                    except as provided for treatment of organi-
    cident to reading therapy; vocational, educa-             cally based conditions;
    tional, recreational, art, dance or music
    therapy; weight control or exercise pro-              32. Speech Therapy. For or incident to speech
    grams; nutritional counseling except as spe-              therapy, speech correction or speech pa-
    cifically provided for under V.;                          thology or speech abnormalities that are not
                                                              likely the result of a diagnosed, identifiable
28. Reconstructive Surgery. For reconstruc-                   medical condition, injury or illness, except
    tive surgery and procedures where there is                as specifically provided under K., M. and
    another more appropriate covered surgical                 O.;
    procedure, or when the surgery or proce-
    dure offers only a minimal improvement in             33. Spinal Manipulation. For spinal manipula-
    the appearance of the enrollee (e.g., spider              tion or adjustment;
    veins). In addition, no benefits will be pro-
    vided for the following surgeries or proce-           34. Therapeutic Devices. Devices or appara-
    dures unless for reconstructive surgery:                  tuses, regardless of therapeutic effect (e.g.,
                                                              hypodermic needles and syringes, except as
    • Surgery to excise, enlarge, reduce, or                  needed for insulin and covered injectable
      change the appearance of any part of                    medication), support garments and similar
      the body;                                               items;
    • Surgery to reform or reshape skin or
      bone;                                               35. Transportation Services. For transporta-
    • Surgery to excise or reduce skin or                     tion services other than provided for under
      connective tissue that is loose, wrin-                  H.;
      kled, sagging, or excessive on any part
      of the body;                                        36. Unapproved Drugs/Medicines. Drugs
    • Hair transplantation; and                               and medicines which cannot be lawfully
                                                              marketed without approval of the U.S. Food

                                                     47
BASIC PLAN
    and Drug Administration (FDA); however,                 41. Not Specifically Listed as a Benefit.
    drugs and medicines which have received
    FDA approval for marketing for one or                   See the Grievance Process section for informa-
    more uses will not be denied on the basis               tion on filing a grievance, your right to seek as-
    that they are being prescribed for an off-              sistance from the Department of Managed
    label use if the conditions set forth in Cali-          Health Care, and your rights to independent
    fornia Health & Safety Code Section                     medical review.
    1367.21 have been met;
                                                            Medical Necessity Exclusion
37. Unauthorized Non-Emergency Services.                    All services must be medically necessary. The
    For unauthorized non-emergency services;                fact that a physician or other provider may pre-
                                                            scribe, order, recommend, or approve a service
38. Unauthorized Treatment. Not provided,                   or supply does not, in itself, make it medically
    prescribed, referred, or authorized as de-              necessary, even though it is not specifically listed
    scribed herein except for Access+ Specialist            as an exclusion or limitation. Blue Shield may
    visits, OB/GYN services provided by an                  limit or exclude benefits for services which are
    obstetrician/gynecologist or a family prac-             not medically necessary.
    tice physician within the same medical
    group or IPA as the Personal Physician,                 Limitations for Duplicate Coverage
    emergency services or urgent services as                In the event that you are covered under the Plan
    provided under the Agreement provisions,                and are also entitled to benefits under any of the
    when specific authorization has been ob-                conditions listed below, Blue Shield’s liability for
    tained in writing for such services as de-              services (including room and board) provided to
    scribed herein, for mental health and                   the Member for the treatment of any one illness
    substance abuse services which must be ar-              or injury shall be reduced by the amount of
    ranged through the MHSA or for hospice                  benefits paid, or the reasonable value or the
    services received by a participating hospice            amount of Blue Shield’s fee-for-service payment
    agency;                                                 to the provider, whichever is less, of the services
                                                            provided without any cost to you, because of
39. Unlicensed Services. For services pro-                  your entitlement to such other benefits. This ex-
    vided by an individual or entity that is not li-        clusion is applicable to benefits received from
    censed or certified by the state to provide             any of the following sources:
    health care services, or is not operating
    within the scope of such license or certifica-          1. Benefits provided under Title 18 of the So-
    tion, except as specifically stated herein;                cial Security Act (“Medicare”). If a Member
                                                               receives services to which he is entitled un-
40. Workers’ Compensation/Work-Related Injury.                 der Medicare and those services are also
    For or incident to any injury or disease aris-             covered under this Plan, the Plan provider
    ing out of, or in the course of, any employ-               may recover the amount paid for the ser-
    ment for salary, wage or profit if such injury             vices under Medicare. This provision does
    or disease is covered by any workers’ com-                 not apply to Medicare Part D (outpatient
    pensation law, occupational disease law or                 prescription drug) benefits. This limitation
    similar legislation. However, if Blue Shield               for Medicare does not apply when the em-
    provides payment for such services it will be              ployer is subject to the Medicare Secondary
    entitled to establish a lien upon such other               Payor Laws and the employer maintains:
    benefits up to the reasonable cash value of
    benefits provided by Blue Shield for the
    treatment of the injury or disease as re-
    flected by the providers’ usual billed
    charges;



                                                       48
BASIC PLAN
    a. an employer group health plan that cov-             General Provisions
       ers                                                 Grievance Process
                                                           Blue Shield of California has established a griev-
       1) persons entitled to Medicare solely
                                                           ance procedure for receiving, resolving and
          because of end-stage renal disease,
                                                           tracking Members’ grievances with Blue Shield
          and
                                                           of California.
       2) active employees or spouses or do-
          mestic partners entitled to Medicare             For all services other than mental health
          by reason of age, and/or                         and substance abuse
                                                           The Member, a designated representative, or a
    b. a large group health plan as defined un-            provider on behalf of the Member, may contact
       der the Medicare Secondary Payor laws               the Member Services Department by telephone,
       that covers persons entitled to Medicare            letter or online to request a review of an initial
       by reason of disability.                            determination concerning a claim or service.
                                                           Members may contact the Plan at the telephone
    This paragraph shall also apply to a Member            number as noted on the back cover of this
    who becomes eligible for Medicare on the               booklet. If the telephone inquiry to Member
    date that he received notice of his eligibility        Services does not resolve the question or issue
    for such enrollment.                                   to the Member’s satisfaction, the Member may
                                                           request a grievance at that time, which the
2. Benefits provided by any other federal or
                                                           Member Services Representative will initiate on
   state governmental agency, or by any county
                                                           the Member’s behalf.
   or other political subdivision, except that
   this exclusion does not apply to Medi-Cal;              Note: You may have the right to receive con-
   or Subchapter 19 (commencing with Section               tinued coverage pending the outcome of your
   1396) of Chapter 7 of Title 42 of the United            grievance. Be advised that, if you qualify for this
   States Code; or for the reasonable costs of             continued coverage and if your grievance is de-
   services provided to the person at a Veter-             nied, you will be held financially responsible for
   ans Administration facility for a condition             any monies paid on your behalf. To request con-
   unrelated to military service or at a Depart-           tinued coverage during your grievance, contact
   ment of Defense facility, provided the per-             Member Services at the telephone number on
   son is not on active duty.                              your identification card.
Exception for Other Coverage                               The Member, a designated representative, or a
A Plan provider may seek reimbursement from                provider on behalf of the Member, may also ini-
other third party payors for the balance of its            tiate a grievance by submitting a letter or a com-
reasonable charges for services rendered under             pleted “Grievance Form.” The Member may
this Plan.                                                 request this form from Member Services. The
                                                           completed form should be submitted to Mem-
Claims and Services Review                                 ber Services at the address as noted on the back
Blue Shield reserves the right to review all               cover of this booklet. The Member may also
claims and services to determine if any exclu-             submit the grievance online by visiting our web
sions or other limitations apply. Blue Shield may          site at http://www.blueshieldca.com.
use the services of physician consultants, peer
review committees of professional societies or             Blue Shield will acknowledge receipt of a griev-
hospitals and other consultants to evaluate                ance within 5 calendar days. Grievances are re-
claims.                                                    solved within 30 days. The grievance system
                                                           allows Members to file grievances for at least
                                                           180 days following any incident or action that is
                                                           the subject of the Member’s dissatisfaction. See


                                                      49
BASIC PLAN
the Member Services Department section for in-             solved within 30 days. The grievance system
formation on the expedited decision process.               allows Members to file grievances for at least
                                                           180 days following any incident or action that is
For all mental health and substance abuse                  the subject of the Member’s dissatisfaction. See
services                                                   the Member Services Department section for in-
The Member, a designated representative, or a              formation on the expedited decision process.
provider on behalf of the Member, may contact
the MHSA by telephone, letter or online to re-             External Independent Medical Review
quest a review of an initial determination con-            If your grievance involves a claim or services for
cerning a claim or service. Members may                    which coverage was denied by Blue Shield or by
contact the MHSA at the telephone number as                a contracting provider in whole or in part on the
noted below. If the telephone inquiry to the               grounds that the service is not medically neces-
MHSA’s Customer Service Department does                    sary or is experimental/investigational (including
not resolve the question or issue to the Mem-              the external review available under the Fried-
ber’s satisfaction, the Member may request a               man-Knowles Experimental Treatment Act of
grievance at that time, which the Customer Ser-            1996), you may choose to make a request to the
vice Representative will initiate on the Member’s          Department of Managed Health Care to have
behalf.                                                    the matter submitted to an independent agency
                                                           for external review in accordance with California
Note: You may have the right to receive con-               law. You normally must first submit a grievance
tinued coverage pending the outcome of your                to Blue Shield and wait for at least 30 days be-
grievance. Be advised that, if you qualify for this        fore you request external review; however, if
continued coverage and if your grievance is de-            your matter would qualify for an expedited deci-
nied, you will be held financially responsible for         sion as described in the Member Services De-
any monies paid on your behalf. To request con-            partment section or involves a determination
tinued coverage during your grievance, contact             that the requested service is experimen-
Member Services at the telephone number on                 tal/investigational, you may immediately request
your identification card.                                  an external review following receipt of notice of
                                                           denial. You may initiate this review by complet-
The Member, a designated representative, or a              ing an application for external review, a copy of
provider on behalf of the Member, may also ini-            which can be obtained by contacting Member
tiate a grievance by submitting a letter or a com-         Services. The Department of Managed Health
pleted “Grievance Form.” The Member may                    Care will review the application and, if the re-
request this form from the MHSA’s Customer                 quest qualifies for external review, will select an
Service Department. If the Member wishes, the              external review agency and have your records
MHSA’s Customer Service staff will assist in               submitted to a qualified specialist for an inde-
completing the Grievance Form. Completed                   pendent determination of whether the care is
grievance forms must be mailed to the MHSA at              medically necessary. You may choose to submit
the address provided below. The Member may                 additional records to the external review agency
also submit the grievance to the MHSA online               for review. There is no cost to you for this ex-
by visiting http://www.blueshieldca.com.                   ternal review. You and your physician will re-
                                                           ceive copies of the opinions of the external
                 1-877-263-9952                            review agency. The decision of the external re-
           Blue Shield of California                       view agency is binding on Blue Shield; if the ex-
      Mental Health Service Administrator                  ternal reviewer determines that the service is
           Attn: Customer Service                          medically necessary, Blue Shield will promptly
              P. O. Box 880609                             arrange for the service to be provided or the
            San Diego, CA 92168                            claim in dispute to be paid. This external review
                                                           process is in addition to any other procedures or
The MHSA will acknowledge receipt of a griev-              remedies available to you and is completely vol-
ance within 5 calendar days. Grievances are re-            untary on your part; you are not obligated to re-

                                                      50
BASIC PLAN
quest external review. However, failure to par-            5. Disputed Health Care Service Issue. A
ticipate in external review may cause you to give             disputed health care service issue concerns
up any statutory right to pursue legal action                 any health care service eligible for coverage
against Blue Shield regarding the disputed ser-               and payment under this Evidence of Cover-
vice. For more information regarding the exter-               age booklet that has been denied, modified,
nal review process, or to request an application              or delayed in whole or in part due to a find-
form, please contact Member Services.                         ing that the service is not medically neces-
                                                              sary. A decision regarding a disputed health
Appeal Procedure Following Disposition                        care service relates to the practice of medi-
of Plan Grievance Procedure                                   cine and is not a coverage issue, and in-
If no resolution of your complaint is achieved                cludes decisions as to whether a particular
by the internal grievance process described                   service is experimental or investigational.
above, you have several options depending on
the nature of your complaint.                                  If you are dissatisfied with the outcome of
                                                               Blue Shield’s internal grievance process or if
1. Eligibility Issues. Refer these matters di-                 you have been in the process for 30 days or
   rectly to CalPERS. Contact CalPERS Office                   more, you may request an independent
   of Employer and Member Health Services                      medical review from the Department of
   at P.O. Box 942714, Sacramento, CA                          Managed Health Care.
   94229-2714, Fax (916) 795-1277, or tele-
   phone CalPERS Customer Service and                          If you are dissatisfied with the outcome of
   Education Division at 888 CalPERS (or                       the independent medical review process,
   888-225-7377), TTY 1-800-735-2929; (916)                    you may request an administrative review
   795-3240.                                                   before the CalPERS Board of Administra-
                                                               tion, or you may proceed to court.
2. Coverage Issues. A coverage issue con-
   cerns the denial or approval of health care             CalPERS Administrative Appeal Process
   services substantially based on a finding that          Only issues of eligibility and coverage issues
   the provision of a particular service is in-            which concern the denial or approval of health
   cluded or excluded as a covered benefit un-             care services substantially based on a finding
   der this Evidence of Coverage booklet. It               that the provision of a particular service is in-
   does not include a plan or contracting pro-             cluded or excluded as a covered benefit under
   vider decision regarding a disputed health              this Evidence of Coverage booklet may be ap-
   care service.                                           pealed directly to CalPERS.

    If you are dissatisfied with the outcome of            CalPERS staff will conduct an administrative
    Blue Shield’s internal grievance process or if         review upon your appeal of Blue Shield’s denial
    you have been in the process for 30 days or            of coverage or the denial of a disputed health
    more, you may request review by the De-                care issue by the Department of Managed
    partment of Managed Health Care, or you                Health Care. However, your written appeal must
    may request an administrative review before            be submitted to CalPERS within 30 days of the
    the CalPERS Board of Administration, or                postmark date of Blue Shield’s letter of denial or
    you may choose Small Claims Court, if your             the Department of Managed Health Care’s de-
    coverage dispute is within the jurisdictional          termination of findings.
    limits of Small Claims Court.
                                                           If the dispute remains unresolved during the
3. Malpractice. You must proceed directly to court.        administrative review process, the matter may
                                                           then proceed to an administrative hearing. Dur-
4. Bad Faith. You must proceed directly to court.          ing the hearing, evidence and testimony will be
                                                           presented to an Administrative Law Judge.



                                                      51
BASIC PLAN
To file for an administrative review, contact              Alternate Arrangements
CalPERS Office of Employer and Member                      Blue Shield will make a reasonable effort to se-
Health Services, P.O. Box 942714, Sacramento,              cure alternate arrangements for the provision of
CA 94229-2714, Fax (916) 795-1277, or tele-                care by another Plan provider without additional
phone CalPERS Customer Service and Educa-                  expense to you in the event a Plan provider’s
tion Division, 888 CalPERS (or 888-225-7377),              contract is terminated, or a Plan provider is un-
TTY 1-800-735-2929; (916) 795-3240.                        able or unwilling to provide care to you.

Department of Managed Health Care                          If such alternate arrangements are not made
Review                                                     available, or are not deemed satisfactory to the
The California Department of Managed Health                Board, then Blue Shield will provide all services
Care is responsible for regulating health care ser-        and/or benefits of the Agreement to you on a
vice plans. If you have a grievance against your           fee-for-service basis (less any applicable copay-
health plan, you should first telephone your               ments), and the limitation contained herein with
health plan at 1-800-334-5847 and use your health          respect to use of a Plan provider shall be of no
plan’s grievance process before contacting the             force or effect.
Department. Utilizing this grievance procedure
does not prohibit any potential legal rights or            Such fee-for-service arrangements shall continue
remedies that may be available to you. If you              until any affected treatment plan has been com-
need help with a grievance involving an emer-              pleted or until such time as you agree to obtain
gency, a grievance that has not been satisfactorily        services from another Plan provider, your en-
resolved by your health plan, or a grievance that          rollment is terminated, or your enrollment is
has remained unresolved for more than 30 days,             transferred to another plan administered by the
you may call the Department for assistance. You            Board, whichever occurs first. In no case, how-
may also be eligible for an Independent Medical            ever, will such fee-for-service arrangements con-
Review (IMR). If you are eligible for IMR, the             tinue beyond the term of the Plan, unless the
IMR process will provide an impartial review of            Extension of Benefits provision applies to you.
medical decisions made by a health plan related to
the medical necessity of a proposed service or             Physician-Patient or Plan-Member
treatment, coverage decisions for treatments that          Relationship
are experimental or investigational in nature and          In the event that Blue Shield of California shall
payment disputes for emergency or urgent medi-             be unable to establish satisfactory physician-
cal services. The Department also has a toll-free          patient or plan-member relationship with any
telephone number (1-888-HMO-2219) and a                    member, after reasonable efforts to do so, then
TDD line (1-877-688-9891) for the hearing and              Blue Shield may either submit the matter for
speech impaired. The Department’s Web site                 consideration under Blue Shield's grievance pro-
(http://www.hmohelp.ca.gov) has complaint                  cedures or submit the matter for consideration
forms, IMR application forms and instructions              by the Chief Executive Officer of CalPERS. In
online.                                                    any event, if it is determined that a satisfactory
                                                           physician-patient or plan-member relationship
In the event that Blue Shield should cancel or             cannot be maintained, then the member shall be
refuse to renew enrollment for you or your de-             provided with the opportunity to change en-
pendents and you feel that such action was due             rollment to another plan.
to health or utilization of benefits, you or your
dependents may request a review by the De-                 Termination of Group Membership -
partment of Managed Health Care Director.                  Continuation of Coverage
                                                           Termination of Benefits
Matters of eligibility should be referred directly
                                                           Coverage for you or your dependents terminates
to CalPERS - contact CalPERS Office of Em-
                                                           at 12:01 a.m. Pacific Time on the earliest of
ployer and Member Health Services, P.O. Box
                                                           these dates: (1) the date the group Agreement is
942714, Sacramento, CA 94229-2714.
                                                           discontinued, (2) the first day of the month fol-

                                                      52
BASIC PLAN
lowing the month in which the subscriber’s em-             Code. If the Member does not access the
ployment terminates, unless a different date has           change of enrollment procedure, Blue Shield
been agreed to between Blue Shield and your                will undertake reasonable efforts to make a Plan
employer, (3) the end of the period for which              physician available to the Member with whom a
the premium is paid, or (4) the first day of the           satisfactory relationship may be developed.
month following the month in which you or
your dependents become ineligible. A spouse                In the event any Member believes that his or her
also becomes ineligible following legal separa-            benefits under this Agreement have been termi-
tion from the subscriber, entry of a final decree          nated because of his or her health status or
of divorce, annulment or dissolution of marriage           health requirements, the Member may seek from
from the subscriber. A domestic partner be-                the Department of Managed Health Care, re-
comes ineligible upon termination of the do-               view of the termination as provided in Califor-
mestic partnership.                                        nia Health & Safety Code Section 1365(b).

Except as specifically provided under the Exten-           Reinstatement
sion of Benefits and COBRA provisions, there               If you cancel or your coverage is terminated, re-
is no right to receive benefits for services pro-          fer to the CalPERS “Health Program Guide.”
vided following termination of this group
Agreement.                                                 Cancellation
                                                           No benefits will be provided for services ren-
If you cease work because of retirement, disabil-          dered after the effective date of cancellation, ex-
ity, leave of absence, temporary layoff or termi-          cept as specifically provided under the
nation, see your employer about possibly                   Individual Conversion Plan, Guaranteed Issue
continuing group coverage. Also, see the Indi-             Individual Coverage, Extension of Benefits, and
vidual Conversion Plan and COBRA and/or                    COBRA provisions in this booklet.
Cal-COBRA provisions described in this book-
let for information on continuation of coverage.           The group Agreement also may be cancelled by
                                                           CalPERS at any time provided written notice is
If the subscriber no longer lives or works in the          given to Blue Shield to become effective upon
Plan service area, coverage will be terminated             receipt, or on a later date as may be specified on
for him and all his dependents. If a dependent             the notice.
no longer lives or works in the Plan service area,
then that dependent's coverage will be termi-              Individual Conversion Plan
nated. (Special arrangements may be available              Regardless of age, physical condition or em-
for dependents who are full-time students, de-             ployment status, you may apply to continue Blue
pendents of subscribers who are required by                Shield protection when you retire, leave the job
court order to provide coverage, and depend-               or become ineligible for group coverage by ap-
ents and subscribers who are long-term travel-             plying for a transfer to an individual conversion
ers. Please contact the Member Services                    plan then being issued by Blue Shield. Except as
Department to request a brochure which ex-                 otherwise provided by California law, you must
plains these arrangements including how long               first elect and exhaust available continuation
coverage is available. This brochure is also avail-        coverage under COBRA and/or Cal-COBRA
able at http://www.blueshieldca.com for HMO                prior to enrolling in a conversion plan.
Members.)
                                                           An application and first dues payment for the
If the relationship between a Plan physician and           conversion plan and the first month’s premium
a Member is unsatisfactory, or if the relationship         must be received by Blue Shield within 63 days
between Blue Shield and a Member is unsatis-               of the date of termination of your Blue Shield
factory, then the Member may submit the mat-               group coverage. However, if the Blue Shield
ter to CalPERS under the change of enrollment              group Agreement is terminated or your em-
procedure in Section 22841 of the Government               ployer withdraws from participation in the Pub-

                                                      53
BASIC PLAN
lic Employees’ Medical and Hospital Care Act,               • You must not be eligible for nor have
transfer to the individual conversion plan will               any other health insurance coverage, in-
not be permitted. You will not be permitted to                cluding a group health plan, Medicare or
transfer to the individual conversion plan if you             Medi-Cal;
failed to continue enrollment or to make contri-            • You must make application to Blue
butions during continuation of enrollment in a                Shield for guaranteed issue coverage
non-pay status according to the Public Employ-                within 63 days of the date of termination
ees’ Medical and Hospital Care Act Regulations.               from the group plan.

A conversion plan is also available to:                   If you elect conversion coverage, continuation
                                                          of group coverage after COBRA and/or Cal-
  • Dependents, if the subscriber dies; or,               COBRA, or other Blue Shield individual plans,
  • Dependents who marry or exceed the                    you will waive your right to this guaranteed issue
    maximum age for dependent coverage                    coverage. For more information, contact a Blue
    under the group plan; or,                             Shield Member Services representative at the
  • Dependents, if the subscriber enters                  telephone number noted on your identification
    military service; or,                                 card.
  • Spouse or domestic partner of a sub-
    scriber if their marriage or domestic                 Extension of Benefits
    partnership has terminated; and,                      If a person becomes totally disabled while val-
  • Dependents, when continuation of cov-                 idly covered under this Plan and continues to be
    erage under COBRA and/or Cal-                         totally disabled on the date group coverage ter-
    COBRA expires, or is terminated.                      minates, Blue Shield will extend the benefits of
                                                          this Plan, subject to all limitations and restric-
Guaranteed Issue Individual Coverage                      tions, for covered services and supplies directly
Under the Health Insurance Portability and Ac-            related to the condition, illness or injury causing
countability Act of 1996 (HIPAA) and under                such total disability until the first to occur of the
California law, you may be entitled to apply for          following: (1) the date the covered person is no
certain of Blue Shield’s individual health plans          longer totally disabled, (2) 12:01 a.m. on the day
on a guaranteed issue basis (which means that             following a period of 12 months from the date
you will not be rejected for underwriting reasons         group coverage terminated, (3) the date on
if you meet the other eligibility requirements,           which the covered person’s maximum benefits
you live or work in Blue Shield’s service area,           are reached, (4) the date on which a replacement
and you agree to pay all required dues). You may          carrier provides coverage to the person without
also be eligible to purchase similar coverage on a        limitation as to the totally disabling condition.
guaranteed issue basis from any other health
plan that sells individual coverage for hospital,         No extension will be granted unless Blue Shield
medical or surgical benefits. Not all Blue Shield         receives written certification by a Plan physician
individual plans are available on a guaranteed is-        of such total disability within 90 days of the date
sue basis under HIPAA. To be eligible, you                on which coverage was terminated, and thereaf-
must meet the following requirements:                     ter at such reasonable intervals as determined by
                                                          Blue Shield.
  • You must have at least 18 or more
    months of creditable coverage;                        COBRA and/or Cal-COBRA
  • Your most recent coverage must have                   Please examine your options carefully before
    been group coverage (COBRA and Cal-                   declining this coverage. You should be aware
    COBRA are considered group coverage                   that companies selling individual health insur-
    for these purposes);                                  ance typically require a review of your medical
  • You must have elected and exhausted all               history that could result in a higher premium or
    COBRA and/or Cal-COBRA coverage                       you could be denied coverage entirely.
    that is available to you;

                                                     54
BASIC PLAN
COBRA                                                       the birth or placement for adoption, and such
If a Member is entitled to elect continuation of            children are enrolled within 30 days of the birth
group coverage under the terms of the Consoli-              or placement for adoption.
dated Omnibus Budget Reconciliation Act
(COBRA) as amended, the following applies:                  1. The employee’s or retiree’s death (and the
                                                               surviving family member is not eligible for a
The COBRA group continuation coverage is                       monthly survivor allowance from CalPERS).
provided through federal legislation and allows
an enrolled active or retired employee or his/her           2. Divorce or legal separation of the covered
enrolled family member who lose their regular                  employee or retiree from the employee’s or
group coverage because of certain “qualifying                  retiree’s spouse or termination of the do-
events” to elect continuation for 18, 29, or 36                mestic partnership.
months.
                                                            3. A dependent child ceases to be a dependent
An eligible active or retired employee or his/her              child.
family member(s) is entitled to elect this cover-
age provided an election is made within 60 days             4. The primary COBRA subscriber becomes
of notification of eligibility and the required                entitled to Medicare.
premiums are paid. The benefits of the con-
tinuation coverage are identical to the group               If elected, COBRA continuation coverage is ef-
plan and the cost of coverage shall be 102% of              fective on the date coverage under the group
the applicable group premiums rate. No em-                  plan terminates.
ployer contribution is available to cover the
premiums.                                                   The COBRA continuation coverage will remain
                                                            in effect for the specified time, or until one of
Two “qualifying events” allow enrollees to re-              the following events terminates the coverage:
quest the continuation coverage for 18 months.
The Member's 18-month period may also be ex-                1. The termination of all employer provided
tended to 29 months if the Member was dis-                     group health plans, or
abled on or before the date of termination or
                                                            2. The enrollee fails to pay the required pre-
reduction in hours of employment, or is deter-
                                                               mium(s) on a timely basis, or
mined to be disabled under the Social Security
Act within the first 60 days of the initial qualify-
                                                            3. The enrollee becomes covered by another
ing event and before the end of the 18-month
                                                               health plan without limitations as to pre-
period (non-disabled eligible family members
                                                               existing conditions, or
are also entitled to this 29-month extension).
                                                            4. The enrollee becomes eligible for Medicare
1. The covered employee’s separation from
                                                               benefits, or
   employment for reasons other than gross
   misconduct.                                              5. The continuation of coverage was extended
                                                               to 29 months and there has been a final de-
2. Reduction in the covered employee’s hours
                                                               termination that the Member is no longer
   to less than half-time.
                                                               disabled.
Four “qualifying events” allow an active or re-
                                                            You will receive notice from your employer of
tired employee’s enrolled family member(s) to
                                                            your eligibility for COBRA continuation cover-
elect the continuation coverage for up to 36
                                                            age if your employment is terminated or your
months. Children born to or placed for adop-
                                                            hours are reduced.
tion with the Member during a COBRA con-
tinuation period may be added as dependents,                Contact your (former) employing agency or
provided the employer is properly notified of               CalPERS directly if you need more information

                                                       55
BASIC PLAN
about your eligibility for COBRA group con-               enrollee must notify Blue Shield at least 30 days
tinuation coverage.                                       before COBRA termination.

Cal-COBRA                                                 Continuation of Group Coverage for
COBRA enrollees who became eligible for CO-               Members on Military Leave
BRA coverage on or after January 1, 2003, and             Continuation of group coverage is available for
who reach the 18-month or 29-month maxi-                  Members on military leave if the Member’s em-
mum available under COBRA, may elect to con-              ployer is subject to the Uniformed Services
tinue coverage under Cal-COBRA for a                      Employment and Re-employment Rights Act
maximum period of 36 months from the date                 (USERRA). Members who are planning to enter
the Member's continuation coverage began un-              the Armed Forces should contact their em-
der COBRA. If elected, the Cal-COBRA cover-               ployer for information about their rights under
age will begin after the COBRA coverage ends.             the USERRA. Employers are responsible to en-
                                                          sure compliance with this act and other state
COBRA enrollees must exhaust all the COBRA                and federal laws regarding leaves of absence in-
coverage to which they are entitled before they           cluding the California Family Rights Act, the
can become eligible to continue coverage under            Family and Medical Leave Act, and Labor Code
Cal-COBRA.                                                requirements for medical disability.

In no event will continuation of group coverage           Continuation of Group Coverage
under COBRA, Cal-COBRA or a combination                   After COBRA and/or Cal-COBRA
of COBRA and Cal-COBRA be extended for                    The following section only applies to enrollees
more than 3 years from the date the qualifying            who became eligible for continuation of group
event has occurred which originally entitled the          coverage after COBRA and/or Cal-COBRA
Member to continue group coverage under this              prior to January 1, 2005:
Plan.
                                                          Certain former employees and dependent
Monthly rates for Cal-COBRA coverage shall be             spouses or dependent domestic partners (includ-
110% of the applicable group monthly rates.               ing a spouse who is divorced from the current
                                                          employee/former employee and/or a spouse
Cal-COBRA enrollees must submit monthly                   who was married to the employee/former em-
rates directly to Blue Shield. The initial monthly        ployee at the time of that employee/former em-
rates must be paid within 45 days of the date the         ployee's death, or a domestic partner whose
Member provided written notification to the               partnership with the current employee/former
Plan of the election to continue coverage and be          employee has terminated and/or a domestic
sent to Blue Shield by first-class mail or other          partner who was in a domestic partner relation-
reliable means. The monthly rate payment must             ship with the employee/former employee at the
equal an amount sufficient to pay any required            time of that employee/former employee’s
amounts that are due. Failure to submit the cor-          death) may be eligible to continue group cover-
rect amount within the 45-day period will dis-            age beyond the date their COBRA and/or Cal-
qualify the Member from continuation coverage.            COBRA coverage ends. Blue Shield will offer
                                                          the extended coverage to former employees of
Blue Shield of California is responsible for noti-
                                                          employers that are subject to the existing CO-
fying COBRA enrollees of their right to possibly
                                                          BRA or Cal-COBRA, and to the former em-
continue coverage under Cal-COBRA at least 90
                                                          ployees’ dependent spouses (including a
calendar days before their COBRA coverage will
                                                          divorced or widowed spouse as defined above)
end. The COBRA enrollee should contact Blue
                                                          or dependent domestic partners (including sur-
Shield for more information about continuing
                                                          viving domestic partners or domestic partners
coverage. If the enrollee elects to apply for con-
                                                          whose partnership was terminated as defined
tinuation of coverage under Cal-COBRA, the
                                                          above). This coverage is subject to the following
                                                          conditions:

                                                     56
BASIC PLAN
1. The former employee worked for the em-                Termination of Continuation Coverage After
   ployer for the prior 5 years and was 60 years         COBRA and/or Cal-COBRA
   of age or older on the date his/her employ-           This coverage will end automatically on the ear-
   ment ended.                                           liest of:

2. The former employee was eligible for and              1. The date the former employee, spouse, or
   elected COBRA and/or Cal-COBRA for                       domestic partner or former spouse or for-
   himself and his dependent spouse (a former               mer domestic partner reaches 65;
   spouse, i.e. a divorced or widowed spouse as
   defined above, is also eligible for continua-         2. The date the employer discontinues this
   tion of group coverage after COBRA                       Agreement and ceases to maintain any
   and/or Cal-COBRA).                                       group health plan for any active employees;

3. The former employee was eligible for and              3. The date the former employee, spouse, or
   elected COBRA and/or Cal-COBRA for                       domestic partner or former spouse or for-
   himself and his dependent domestic partner               mer domestic partner transfers to another
   (a former domestic partner, i.e., a surviving            health plan, whether or not the benefits of
   domestic partner or domestic partner whose               the other health plan are less valuable than
   partnership has been terminated as defined               those of the health plan maintained by the
   above, is also eligible for continuation of              employer;
   group coverage after COBRA and/or Cal-
   COBRA).                                               4. The date the former employee, spouse, or
                                                            domestic partner or former spouse or for-
Items 1., 2. and 3. above are not applicable to a           mer domestic partner becomes eligible for
former spouse or former domestic partner elect-             Medicare;
ing continuation coverage. The former spouse
or former domestic partner must elect such               5. For a spouse or domestic partner or former
coverage by notifying the plan in writing within            spouse or former domestic partner, 5 years
30 calendar days prior to the date that the for-            from the date the spouse’s or domestic
mer spouse's or former domestic partner’s initial           partner’s COBRA or Cal-COBRA coverage
COBRA and/or Cal-COBRA benefits are                         would end.
scheduled to end.
                                                         Payment by Third Parties
If elected, this coverage will begin after the           Third Party Recovery Process and
COBRA and/or Cal-COBRA coverage ends                     the Member’s Responsibility
and will be administered under the same terms            If a Member is injured through the act or omis-
and conditions as if COBRA and/or Cal-                   sion of another person (a “third party”), Blue
COBRA had remained in force.                             Shield, the Member’s designated medical group,
                                                         and the independent practice association shall,
For Members who transfer to this coverage
                                                         with respect to services required as a result of
from COBRA, monthly rates for this coverage
                                                         that injury, provide the benefits of the Plan and
shall be 213% of the applicable group monthly
                                                         have an equitable right to restitution or other
rate or 102% of the applicable age adjusted
                                                         available remedy to recover the reasonable costs
group monthly rate. For Members who transfer
                                                         of services provided to the Member. The Mem-
to this coverage from Cal-COBRA, monthly
                                                         ber is required to:
rates for this coverage shall be 213% of the ap-
plicable group monthly rate, or 110% of the ap-          1. Notify Blue Shield in writing of any actual
plicable age adjusted group monthly rate.                   or potential claim or legal action which such
Payment is due at the time the employer's pay-              Member anticipates bringing or has brought
ment is due.                                                against the third party arising from the al-
                                                            leged acts or omissions causing the injury or

                                                    57
BASIC PLAN
    illness, not later than 30 days after submit-            for the treatment of the injury or disease as re-
    ting or filing a claim or legal action against           flected by the providers’ usual billed charges.
    the third party; and
                                                             Coordination of Benefits
2. Agree to fully cooperate with Blue Shield,                When a person who is covered under this group
   the Member’s designated medical group,                    Plan is also covered under another group plan,
   and the independent practice association to               or selected group, or blanket disability insurance
   execute any forms or documents needed to                  contract, or any other contractual arrangement
   assist them in exercising their equitable right           or any portion of any such arrangement
   to restitution or other available remedies;               whereby the members of a group are entitled to
   and                                                       payment of or reimbursement for hospital or
                                                             medical expenses, such person will not be per-
3. Provide Blue Shield, the Member’s desig-                  mitted to make a “profit” on a disability by col-
   nated medical group, and the independent                  lecting benefits in excess of actual value or cost
   practice association with a lien in the                   during any calendar year.
   amount of the reasonable costs of benefits
   provided, calculated in accordance with                   Instead, payments will be coordinated between
   California Civil Code section 3040. The lien              the plans in order to provide for “allowable ex-
   may be filed with the third party, the third              penses” (these are the expenses that are incurred
   party’s agent or attorney, or the court unless            for services and supplies covered under at least
   otherwise prohibited by law.                              one of the plans involved) up to the maximum
                                                             benefit value or amount payable by each plan
A Member’s failure to comply with 1. through                 separately.
3., above, shall not in any way act as a waiver,
release, or relinquishment of the rights of Blue             If the covered person is also entitled to benefits
Shield, the Member's designated medical group,               under any of the conditions as outlined under
or the independent practice association.                     the Limitations for Duplicate Coverage provi-
                                                             sion, benefits received under any such condition
Further, if the Member receives services from a              will not be coordinated with the benefits of this
Plan hospital for such injuries, the hospital has            Plan. The following rules determine the order of
the right to collect from the Member the differ-             benefit payments:
ence between the amount paid by Blue Shield
and the hospital’s reasonable and necessary                  When the other plan does not have a coordina-
charges for such services when payment or re-                tion of benefits provision, it will always provide
imbursement is received by the Member for                    its benefits first. Otherwise, the plan covering
medical expenses. The Plan hospital’s right to               the patient as an employee will provide its bene-
collect shall be in accordance with California               fits before the plan covering the patient as a de-
Civil Code Section 3045.1.                                   pendent.

Workers’ Compensation                                        Except for cases of claims for a dependent child
No benefits are provided for or incident to any              whose parents are separated or divorced, the
injury or disease arising out of, or in the course           plan which covers the dependent child of a per-
of, any employment for salary, wage or profit if             son whose date of birth (excluding year of birth)
such injury or disease is covered by any workers’            occurs earlier in a calendar year, shall determine
compensation law, occupational disease law or                its benefits before a plan which covers the de-
similar legislation.                                         pendent child of a person whose date of birth
                                                             (excluding year of birth) occurs later in a calen-
However, if Blue Shield provides payment for                 dar year. If either plan does not have the provi-
such services it will be entitled to establish a lien        sions of this paragraph regarding dependents,
upon such other benefits up to the reasonable                which results either in each plan determining its
cash value of benefits provided by Blue Shield               benefits before the other or in each plan deter-


                                                        58
BASIC PLAN
mining its benefits after the other, the provi-            When this Plan is secondary in the order of
sions of this paragraph shall not apply, and the           payments, and Blue Shield is notified that there
rule set forth in the plan which does not have             is a dispute as to which plan is primary, or that
the provisions of this paragraph shall determine           the primary plan has not paid within a reason-
the order of benefits.                                     able period of time, this Plan will provide the
                                                           benefits that would be due as if it were the pri-
1. In the case of a claim involving expenses for           mary plan, provided that the covered person:
   a dependent child whose parents are sepa-               (1) assigns to Blue Shield the right to receive
   rated or divorced, plans covering the child             benefits from the other plan to the extent of the
   as a dependent shall determine their respec-            difference between the value of the benefits
   tive benefits in the following order: First,            which Blue Shield actually provides and the
   the plan of the parent with custody of the              value of the benefits that Blue Shield would
   child; then, if that parent has remarried, the          have been obligated to provide as the secondary
   plan of the stepparent with custody of the              plan, (2) agrees to cooperate fully with Blue
   child; and finally the plan(s) of the parent(s)         Shield in obtaining payment of benefits from
   without custody of the child.                           the other plan, and (3) allows Blue Shield to ob-
                                                           tain confirmation from the other plan that the
2. Notwithstanding 1. above, if there is a court           benefits which are claimed have not previously
   decree which otherwise establishes financial            been paid.
   responsibility for the medical, dental or
   other health care expenses of the child, then           If payments which should have been made un-
   the plan which covers the child as a depend-            der this Plan in accordance with these provi-
   ent of the parent with that financial respon-           sions have been made by another Plan, Blue
   sibility shall determine its benefits before            Shield may pay to the other Plan the amount
   any other plan which covers the child as a              necessary to satisfy the intent of these provi-
   dependent child.                                        sions. This amount shall be considered as bene-
                                                           fits paid under this Plan. Blue Shield shall be
3. If the above rules do not apply, the plan               fully discharged from liability under this Plan to
   which has covered the patient for the longer            the extent of these payments.
   period of time shall determine its benefits
   first, provided that:                                   If payments have been made by Blue Shield in
                                                           excess of the maximum amount of payment
    a. A plan covering a patient as a laid-off or          necessary to satisfy these provisions, Blue Shield
       retired employee, or as a dependent of              shall have the right to recover the excess from
       such an employee, shall determine its               any person or other entity to or with respect to
       benefits after any other plan covering              whom such payments were made.
       that person as an employee, other than a
       laid-off or retired employee, or such de-           Blue Shield may release to or obtain from any
       pendent; and,                                       organization or person any information which
                                                           Blue Shield considers necessary for the purpose
    b. If either plan does not have a provision            of determining the applicability of and imple-
       regarding laid-off or retired employees,            menting the terms of these provisions or any
       which results in each plan determining its          provisions of similar purpose of any other Plan.
       benefits after the other, then the provi-           Any person claiming benefits under this Plan
       sions of a. above shall not apply.                  shall furnish Blue Shield with such information
                                                           as may be necessary to implement these provi-
If this Plan is the primary carrier with respect to
                                                           sions.
a covered person, then this Plan will provide its
benefits without reduction because of benefits
available from any other plan.



                                                      59
BASIC PLAN
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                                      60
                                                                                                                              Table of Contents
                                                                                                                                                                   Page
Section 2 - Supplement to Original Medicare Plan
 Summary of Covered Services ........................................................................................................... 63
 Benefit Changes for Current Year .................................................................................................... 65
 Eligibility........................................................................................................................................................... 65
 Enrollment ....................................................................................................................................................... 66
 How to Use the Plan .................................................................................................................................. 66
   Choice of Physicians and Providers............................................................................................................. 66
   Payment of Providers ..................................................................................................................................... 66
   Selecting a Personal Physician....................................................................................................................... 66
   Role of the Medical Group or IPA .............................................................................................................. 67
   Changing Personal Physicians or Designated Medical Group or IPA ................................................... 68
   Continuity of Care by a Terminated Provider............................................................................................ 68
   Relationship With Your Personal Physician ............................................................................................... 69
   How to Receive Care...................................................................................................................................... 69
   Use of Personal Physician.............................................................................................................................. 69
   Obstetrical/Gynecological (OB/GYN) Physician Services..................................................................... 69
   Referral to Specialty Services and Second Medical Opinions .................................................................. 70
   Access+ Specialist........................................................................................................................................... 71
   NurseHelp 24/7 and LifeReferrals 24/7..................................................................................................... 72
   Mental Health and Substance Abuse Services............................................................................................ 72
   Emergency Services ........................................................................................................................................ 73
   Urgent Services................................................................................................................................................ 74
   Inpatient, Home Health Care and Other Services..................................................................................... 75
   Liability of Member for Payment ................................................................................................................. 76
   Limitation of Liability..................................................................................................................................... 76
   Member Identification Card.......................................................................................................................... 76
   Member Services Department ...................................................................................................................... 76
 Rates for Supplement to Original Medicare Plan ..................................................................... 77
   State Employees and Annuitants.................................................................................................................. 77
   Contracting Agency Employees and Annuitants ....................................................................................... 77
 Benefit Descriptions ................................................................................................................................. 78
   Hospital Services ............................................................................................................................................. 78
   Physician Services (Other Than for Mental Health and Substance Abuse Services) ........................... 79
   Preventive Health Services ............................................................................................................................ 80
   Diagnostic X-ray/Lab Services..................................................................................................................... 80
   Durable Medical Equipment, Prostheses and Orthoses and Other Services ........................................ 80
   Pregnancy and Maternity Care ...................................................................................................................... 82
   Family Planning and Infertility Services ...................................................................................................... 82
   Ambulance Services........................................................................................................................................ 83
   Emergency Services ........................................................................................................................................ 83
   Urgent Services................................................................................................................................................ 84
   Home Health Care Services, PKU-Related Formulas and Special Food Products, and Home Infusion Therapy. 85
   Physical and Occupational Therapy............................................................................................................. 87
   Speech Therapy ............................................................................................................................................... 87
   Skilled Nursing Facility Services ................................................................................................................... 88
   Hospice Program Services............................................................................................................................. 88
   Prescription Drugs.......................................................................................................................................... 91
   Inpatient Mental Health and Substance Abuse Services........................................................................... 96




                                                                                61
Table of Contents
                                                                                                                                                                    Page
  Benefit Descriptions, Continued
    Outpatient Mental Health and Substance Abuse Services ........................................................................96
    Medical Treatment of the Teeth, Gums, Jaw Joints or Jaw Bones..........................................................97
    Special Transplant Benefits ............................................................................................................................97
    Organ Transplant Benefits .............................................................................................................................98
    Diabetes Care ...................................................................................................................................................98
    Reconstructive Surgery ...................................................................................................................................99
    Clinical Trials for Cancer................................................................................................................................99
    Medicare Part B Covered Drugs and Supplies..........................................................................................100
    Additional Services ........................................................................................................................................101
  Exclusions and Limitations .................................................................................................................102
    General Exclusions and Limitations...........................................................................................................102
    Medical Necessity Exclusion........................................................................................................................106
    Limitations for Duplicate Coverage............................................................................................................106
    Exception for Other Coverage....................................................................................................................106
    Claims and Services Review .........................................................................................................................106
  General Provisions ...................................................................................................................................106
    Grievance Process .........................................................................................................................................106
    Appeal Procedure Following Disposition of Plan Grievance Procedure .............................................108
    CalPERS Administrative Appeal Process ..................................................................................................108
    Department of Managed Health Care Review ..........................................................................................109
    Alternate Arrangements................................................................................................................................109
    Physician-Patient or Plan-Member Relationship ......................................................................................110
    Advance Directives........................................................................................................................................110
  Termination of Group Membership - Continuation of Coverage ..................................110
    Termination of Benefits................................................................................................................................110
    Reinstatement.................................................................................................................................................111
    Cancellation ....................................................................................................................................................111
    Extension of Benefits....................................................................................................................................111
    COBRA and/or Cal-COBRA......................................................................................................................111
  Payment by Third Parties .....................................................................................................................113
    Third Party Recovery Process and the Member’s Responsibility ..........................................................113
    Workers’ Compensation ...............................................................................................................................113
    Coordination of Benefits ..............................................................................................................................113
Section 3 - General Information for All Members .....................................................117
  Definitions ......................................................................................................................................................117
   Members Rights and Responsibilities.........................................................................................................123
   Public Policy Participation Procedure ........................................................................................................125
   Confidentiality of Medical Records and Personal Health Information.................................................125
   Access to Information ..................................................................................................................................126
   Non-Assignability ..........................................................................................................................................126
   Facilities...........................................................................................................................................................126
   Independent Contractors .............................................................................................................................127
   Access+ Satisfaction......................................................................................................................................127
   Web Site ..........................................................................................................................................................127
   Utilization Review Process...........................................................................................................................127
   Notice of the Availability of Language Assistance Services....................................................................128
  Service Area ..................................................................................................................................................129




                                                                                 62
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
THIS IS ONLY A BRIEF SUMMARY. REFER TO THE BENEFIT DESCRIPTIONS AND
LIMITATIONS IN THIS BOOK FOR FURTHER INFORMATION.*

                                Summary of Covered Services
                Category Description                         Member Copayment & Limitations
Hospital
    Inpatient                                                             No Charge
         (includes blood and blood products -
         collection and storage of autologous blood)
    Outpatient                                                            No Charge
Physician Services
    Office/Home Visits                                                     $10/visit
    Allergy Testing/Treatment                                              $10/visit
    Inpatient Hospital Visits                                             No Charge
    Surgery/Anesthesia                                                    No Charge
    Access+ Specialist                                                     $30/visit
Preventive Health                                                         No Charge
Diagnostic X-ray/Lab                                                      No Charge
Durable Medical Equipment                                                 No Charge
    (including orthoses and prostheses)
Pregnancy & Maternity
    Prenatal and Postnatal Physician Office Visits                        No Charge
Family Planning Counseling                                                No Charge
Infertility Testing & Treatment                                     50% of Allowed Charges
Ambulance Services                                                        No Charge
                                                        $50/visit - does not apply if hospitalized or
Emergency Care/Services                                 kept for observation and hospital bills for an
                                                        emergency room observation visit
Urgent Services                                                            $25/visit
Home Health Services                                                      No Charge
Physical/Occupational/Speech Therapy                                       $10/visit
Skilled Nursing Care                                    No Charge for 100 days per Medicare Benefit
                                                        Period.
Hospice                                                                   No Charge
Biofeedback                                                               No Charge
Chiropractic Care                                                          $10/visit




                                                   63
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
THIS IS ONLY A BRIEF SUMMARY. REFER TO THE BENEFIT DESCRIPTIONS AND
LIMITATIONS IN THIS BOOK FOR FURTHER INFORMATION.
                               Summary of Covered Services
                Category Description                          Member Copayment & Limitations
                                                        Pharmacy: $5 generic, $15 brand name, $45
                                                        non-Formulary, $30 for specialty drugs, 50% of
Prescription Drugs                                      the contracted rate for drugs for erectile dys-
                                                        function/prescription - not to exceed a 30-day
                                                        supply for short-term or acute illness; Mainte-
                                                        nance drugs after 3 months: $10 generic, $25
                                                        brand name, $75 non-Formulary/
                                                        prescription - not to exceed a 30-day supply.

                                                        Mail order: $10 generic, $25 brand name, $75
                                                        non-Formulary/prescription - not to exceed a
                                                        90-day supply for Maintenance drugs; $1,000
                                                        out-of-pocket annual maximum excluding non-
                                                        Formulary drugs.
Medicare Part B Covered Drugs & Supplies                                  No Charge
Mental Health
  Inpatient                                                                   No Charge
   Outpatient                                                                  $10/visit
Substance Abuse
   Inpatient                                                                  No Charge
   Outpatient
                                                                               $10/visit
Vision Care
    Eye Refraction to determine need for                $10/visit. (However, this service is limited to one visit
    corrective lenses                                   per calendar year for Members aged 18 and over. No
                                                        limit on number of visits for Members under age 18.)
  Eyeglasses                                            Not Covered, except for eyeglasses that are
      (benefit beyond Medicare coverage)                necessary after cataract surgery.
Hearing Aid Services
  Audiological Evaluation                                                     No Charge
   Hearing Aid up to a maximum of $1,000 per                        Charges in excess of $1,000
   Member every 36 months for both ears for the
   hearing aid instrument and ancillary equipment

* The statement of benefits, exclusions and limitations in this Evidence of Coverage is complete and
  is incorporated by reference into the contract.




                                                64
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
This plan is available to all CalPERS annuitants          AFTER THE EFFECTIVE DATE OF
or dependents who are eligible for Medicare ex-           MODIFICATION. THERE IS NO VESTED
cept those who live or work in the following              RIGHT TO RECEIVE THE BENEFITS OF
counties in the service area: Fresno (partial             THIS PLAN.
county), Kern (partial county), Los Angeles,
Madera (partial county), Orange, Riverside (par-          Eligibility
tial county), San Bernardino (partial county), San        Information pertaining to your eligibility, en-
Luis Obispo, and Ventura. Annuitants or de-               rollment, cancellation or termination of cover-
pendents in these counties who are eligible for           age, conversion rights, etc. can be found in the
Medicare should request information about the             CalPERS informational booklet “Health Pro-
CalPERS Blue Shield 65 Plus (HMO) Group                   gram Guide.” The booklet is prepared by
Medicare Advantage-Prescription Drug Plan.                CalPERS Office of Employer and Member
                                                          Health Services in Sacramento. You can order
Benefit Changes for Current Year                          this booklet using the postage-paid order card
Hemophilia Infusion                                       included in the Open Enrollment mailing,
Blue Shield is providing more focused support             through      the     CalPERS         Web     site
to Members who use hemophilia services as de-             (http://www.calpers.ca.gov), by calling CalPERS,
scribed in Section K.                                     or by contacting your Health Benefits Officer.

Prescription Drugs                                        If you or any of your dependents are currently
Smoking cessation classes are no longer required          eligible or become eligible for Medicare and you
but will be reimbursed up to $100 per year.               are not an active employee, you may enroll in
Coverage is added for specialty drugs to treat            the Blue Shield Access+ HMO Supplement to
complex or chronic conditions, which must be              Original Medicare Plan. You may also enroll in
obtained from a Blue Shield specialty pharmacy.           the Access+ HMO Supplement to Original Medi-
The copayment reduction is changed to $40 for             care Plan if it is determined for any other reason
retail and $70 for mail. Members will be respon-          that Medicare is the primary payor for you or your
sible for 50% of the contracted rate for erectile         spouse under the Medicare Secondary Payor laws
dysfunction drugs. Non-Formulary drugs are                (e.g., for end-stage renal disease). You are re-
excluded from the mail order out-of-pocket an-            quired to enroll in both Medicare Parts A and B
nual maximum.                                             to be eligible for Blue Shield Access+ HMO
                                                          Supplement to Original Medicare Plan benefits
Reconstructive Surgery                                    and to provide CalPERS Office of Employer
To comply with SB630, Blue Shield is covering             and Member Health Services with a copy of
dental and orthodontic services that are an inte-         your Medicare card or Letter Of Entitlement
gral part of reconstructive surgery for cleft pal-        with a letter to CalPERS requesting enrollment.
ate procedures.
                                                          A Medicare prescription drug program, known
BENEFITS OF THIS PLAN ARE AVAIL-                          as Medicare Part D, became effective January 1,
ABLE ONLY FOR SERVICES AND SUP-                           2006. Blue Shield Supplement to Original Medi-
PLIES FURNISHED DURING THE TERM                           care members do not need to enroll in Medicare
THE PLAN IS IN EFFECT AND WHILE                           Part D because your current Blue Shield pre-
THE INDIVIDUAL CLAIMING BENEFITS                          scription drug benefit as specified by CalPERS
IS ACTUALLY COVERED BY THE GROUP                          is superior in both benefit and cost.
AGREEMENT.
                                                          The Blue Shield Access+ HMO benefits will be
IF BENEFITS ARE MODIFIED, THE RE-                         reduced by the benefits covered by both Medi-
VISED BENEFITS (INCLUDING ANY                             care Part A (hospital benefits) and Medicare
REDUCTION IN BENEFITS OR ELIMI-                           Part B (professional benefits), but not for Medi-
NATION OF BENEFITS) APPLY TO SER-                         care Part D (prescription drugs). The Blue Shield
VICES OR SUPPLIES FURNISHED ON OR                         Access+ HMO will cover benefits only to the

                                                     65
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
extent services are coordinated by your Personal         Benefits of this Plan become effective at 12:01
Physician and authorized by the Blue Shield Ac-          a.m. Pacific Time on the eligibility date estab-
cess+ HMO. This Plan does not cover custodial            lished by CalPERS.
care. Benefits are provided for covered services
whether or not they are covered by Medicare. If          Enrollment
the covered services are also covered by Medi-           Information pertaining to enrollment can be
care, then the Plan providers who render those           found in the CalPERS “Health Program
services will bill and seek payment directly from        Guide.” To enroll or make changes, active
Medicare. You are not responsible for the                members must submit a completed Health
amounts not paid by Medicare for covered ser-            Benefit Enrollment Form (CalPERS HBD-12).
vices, except for the copayment amounts set              Retired members must submit a signed, written
forth in this Evidence of Coverage.                      request or a completed Health Plan Change Re-
                                                         quest Form for Retirees (CalPERS HBD-30). If
Under the Public Employees’ Medical and Hos-             you need assistance in completing these forms,
pital Care Act (PEMHCA), if you are Medicare             contact CalPERS Office of Employer and
eligible and do not enroll in Medicare Parts A           Member Health Services.
and B and a CalPERS Medicare health plan, you
and your enrolled dependents will be excluded            How to Use the Plan
from coverage under the CalPERS program.                 Choice of Physicians and Providers
                                                         PLEASE READ THE FOLLOWING IN-
If either you or your spouse is over the age of
                                                         FORMATION SO YOU WILL KNOW
65 and you are actively employed, neither you
                                                         FROM WHOM OR WHAT GROUP OF
nor your spouse is eligible for Supplement to
                                                         PROVIDERS HEALTH CARE MAY BE
Original Medicare Plan benefits (unless it is de-
                                                         OBTAINED.
termined that Medicare is the primary payor for
you or your spouse under the Medicare Secondary
                                                         Payment of Providers
Payor laws).
                                                         Blue Shield generally contracts with groups of
For answers to questions regarding Medicare,             physicians to provide services to Members. A
contact your local Social Security office or call        fixed, monthly fee is paid to these groups of
Medicare's toll-free number 1-800-633-4227.              physicians for each Member whose Personal
You may also visit the Medicare Web site at              Physician is in the group. This payment system,
http://www.medicare.gov.                                 capitation, includes incentives to the groups of
                                                         physicians to manage all services provided to
Remember, it is your responsibility to stay in-          Members in an appropriate manner consistent
formed about your coverage. If you have any              with the Agreement.
questions, consult your Health Benefits Officer
in your agency or the retirement system from             If you want to know more about this payment
which you receive your allowance, or contact             system, contact Member Services at the number
CalPERS at the address or telephone number               listed on the back cover of this booklet or talk
shown below:                                             to your Plan provider.

CalPERS Office of Employer and Member                    Selecting a Personal Physician
Health Services, P.O. Box 942714, Sacramento,            A close physician-to-patient relationship is an
CA 94229-2714, Fax (916) 795-1277                        important ingredient that helps to ensure the
                                                         best medical care. Each Member is therefore re-
CalPERS Customer Service and Education Di-               quired to select a Personal Physician at the time
vision                                                   of enrollment. Family members can choose dif-
     Toll free 888 CalPERS (or 888-225-7377)             ferent Personal Physicians in different medical
     TTY 1-800-735-2929; (916) 795-3240                  groups or IPAs, except as described for new-
                                                         borns below. This decision is an important one
                                                         because your Personal Physician will:

                                                    66
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
 • Help you decide on actions to maintain                 group or IPA as the subscriber. If you do not
   and improve your total health;                         select a Personal Physician within 31 days fol-
 • Coordinate and direct all of your medical              lowing the birth or placement for adoption, the
   care needs;                                            Plan will designate a Personal Physician from
 • Authorize emergency services when ap-                  the same medical group or IPA as the natural
   propriate;                                             mother or the subscriber. This designation will
 • Work with your medical group or IPA to                 remain in effect for the first calendar month
   arrange your referrals to specialty physi-             during which the birth or placement for adop-
   cians, hospitals and all other health ser-             tion occurred. If you want to change the Per-
   vices, including requesting any prior                  sonal Physician for the child after the month of
   authorization you will need;                           birth or placement for adoption, see the section
 • Prescribe those lab tests, x-rays and ser-             below on Changing Personal Physicians or Des-
   vices you require;                                     ignated Medical Group or IPA. If your child is
 • If you request it, assist you in obtaining             ill during the first month of coverage, be sure to
   prior approval from the Mental Health                  read the information about changing Personal
   Service Administrator (MHSA) for men-                  Physicians during a course of treatment or hos-
   tal health and substance abuse services.               pitalization.
   See the Mental Health and Substance
                                                          Remember that if you want your child covered
   Abuse Services paragraphs in the How
                                                          beyond the 31 days from the date of birth or
   to Use the Plan section for information;
                                                          placement for adoption, you should contact
   and,
                                                          CalPERS Office of Employer and Member
 • Assist you in applying for admission into
                                                          Health Services and Blue Shield to add your
   a hospice program through a participat-
                                                          child to your coverage.
   ing hospice agency when necessary.

To ensure access to services, each Member must
                                                          Role of the Medical Group or IPA
select a Personal Physician who is located suffi-         Most Blue Shield Access+ HMO Personal Phy-
ciently close to the Member’s home or work ad-            sicians contract with medical groups or IPAs to
dress to ensure reasonable access to care, as             share administrative and authorization responsi-
determined by Blue Shield. If you do not select           bilities with them. (Of note, some Personal Phy-
a Personal Physician at the time of enrollment,           sicians contract directly with Blue Shield.) Your
the Plan will designate a Personal Physician for          Personal Physician coordinates with your desig-
you and you will be notified of the name of the           nated medical group or IPA to direct all of your
designated Personal Physician. This designation           medical care needs and refer you to specialists
will remain in effect until you notify the Plan of        or hospitals within your designated medical
your selection of a different Personal Physician.         group or IPA unless because of your health
                                                          condition, care is unavailable within the medical
A Personal Physician must also be selected for a          group or IPA.
newborn or child placed for adoption, prefera-
bly prior to birth or adoption, but always within         Your designated medical group or IPA (or Blue
31 days from the date of birth or placement for           Shield when noted on your identification card)
adoption. You may designate a pediatrician as             ensures that a full panel of specialists is available
the Personal Physician for your child. The Per-           to provide your health care needs and helps
sonal Physician selected for the month of birth           your Personal Physician manage the utilization
must be in the same medical group or IPA as               of your health plan benefits by ensuring that re-
the mother’s Personal Physician when the new-             ferrals are directed to providers who are con-
born is the natural child of the mother. If the           tracted with them. Medical groups or IPAs also
mother of the newborn is not enrolled as a                have admitting arrangements with hospitals con-
Member or if the child has been placed with the           tracted with Blue Shield in their area and some
subscriber for adoption, the Personal Physician           have special arrangements that designate a spe-
selected must be a physician in the same medical          cific hospital as “in network.” Your designated

                                                     67
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
medical group or IPA works with your Personal              tive date of your new medical group or IPA will
Physician to authorize services and ensure that            be the first of the month following discharge
that service is performed by their in network              from the hospital, or when pregnant, following
provider.                                                  the completion of post-partum care.

The name of your Personal Physician and your               Additionally, changing your Personal Physician
designated medical group or IPA (or, “Blue                 or designated medical group or IPA during a
Shield Administered”) is listed on your Access+            course of treatment may interrupt the quality
HMO identification card. The Blue Shield                   and continuity of your health care. For this rea-
HMO Member Services Department can answer                  son, the effective date of your new Personal
any questions you may have about changing the              Physician or designated medical group or IPA,
medical group or IPA designated for your Per-              when requested during a course of treatment,
sonal Physician and whether the change would               will be the first of the month following the date
affect your ability to receive services from a par-        it is medically appropriate to transfer your care
ticular specialist or hospital.                            to your new Personal Physician or designated
                                                           medical group or IPA, as determined by the
Changing Personal Physicians or                            Plan.
Designated Medical Group or IPA
You or your dependent may change Personal                  Exceptions must be approved by the Blue
Physicians or designated medical group or IPA              Shield Medical Director. For information about
by calling the Member Services Department at               approval for an exception to the above provi-
1-800-334-5847. Some Personal Physicians are               sion, please contact Member Services.
affiliated with more than one medical group or
IPA. If you change to a medical group or IPA               If your Personal Physician discontinues partici-
with no affiliation to your Personal Physician,            pation in the Plan, Blue Shield will notify you in
you must select a new Personal Physician affili-           writing and designate a new Personal Physician
ated with the new medical group or IPA and                 for you in case you need immediate medical
transition any specialty care you are receiving to         care. You will also be given the opportunity to
specialists affiliated with the new medical group          select a new Personal Physician of your own
or IPA. The change will be effective the first day         choice within 15 days of this notification. Your
of the month following notice of approval by               selection must be approved by Blue Shield prior
Blue Shield. Once your Personal Physician                  to receiving any services under the Plan. In the
change is effective, all care must be provided or          event that your selection has not been approved
arranged by the new Personal Physician, except             and an emergency arises, see I. Emergency Ser-
for OB/GYN services provided by an obstetri-               vices in the Benefit Descriptions section for in-
cian/gynecologist or a family practice physician           formation.
within the same medical group or IPA as your
Personal Physician and Access+ Specialist visits.          IT IS IMPORTANT TO KNOW THAT
Once your medical group or IPA change is ef-               WHEN YOU ENROLL IN THE BLUE
fective, all previous authorizations for specialty         SHIELD ACCESS+ HMO, SERVICES ARE
care or procedures are no longer valid and must            PROVIDED THROUGH THE PLAN’S DE-
be transitioned to specialists affiliated with the         LIVERY SYSTEM, BUT THE CONTINUED
new medical group or IPA, even if you remain               PARTICIPATION OF ANY ONE DOCTOR,
with the same Personal Physician. Member Ser-              HOSPITAL OR OTHER PROVIDER CAN-
vices will assist you with the timing and choice           NOT BE GUARANTEED.
of a new Personal Physician or medical group or
IPA.                                                       Continuity of Care by a Terminated
                                                           Provider
Voluntary medical group or IPA changes are                 Members who are being treated for acute condi-
not permitted during the third trimester of preg-          tions, serious chronic conditions, pregnancies
nancy or while confined to a hospital. The effec-          (including immediate postpartum care), or ter-

                                                      68
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
minal illness; or who are children from birth to           How to Receive Care
36 months of age; or who have received au-                 Use of Personal Physician
thorization from a now-terminated provider for             At the time of enrollment, you will choose a
surgery or another procedure as part of a docu-            Personal Physician who will coordinate all cov-
mented course of treatment can request comple-             ered services. You must contact your Personal
tion of care in certain situations with a provider         Physician for all health care needs, including
who is leaving the Blue Shield provider network.           preventive services, routine health problems,
Contact Member Services to receive information             consultations with Plan specialists (except as
regarding eligibility criteria and the policy and          provided under Obstetrical/Gynecological
procedure for requesting continuity of care from           (OB/GYN) Physician Services, Access+ Spe-
a terminated provider.                                     cialist, and Mental Health and Substance Abuse
                                                           Services), admission into a hospice program
Relationship With Your Personal                            through a participating hospice agency, emer-
Physician                                                  gency services, urgent services and for hospitali-
The physician-patient relationship you and your            zation. The Personal Physician is responsible for
Personal Physician establish is very important.            providing primary care and coordinating or ar-
The best effort of your Personal Physician will            ranging for referral to other necessary health
be used to ensure that all medically necessary             care services and requesting any needed prior
and appropriate professional services are pro-             authorization. You should cancel any scheduled
vided to you in a manner compatible with your              appointments at least 24 hours in advance. This
wishes. If your Personal Physician recommends              policy applies to appointments with or arranged
procedures or treatments which you refuse, or              by your Personal Physician or the Mental Health
you and your Personal Physician fail to establish          Service Administrator (MHSA) and self-
a satisfactory relationship, you may select a dif-         arranged appointments to an Access+ Specialist
ferent Personal Physician. Member Services can             or for OB/GYN services. Because your physi-
assist you with this selection.                            cian has set aside time for your appointments in
                                                           a busy schedule, you need to notify the office
Your Personal Physician will advise you if he be-          within 24 hours if you are unable to keep the
lieves that there is no professionally acceptable          appointment. That will allow the office staff to
alternative to a recommended treatment or pro-             offer that time slot to another patient who needs
cedure. If you continue to refuse to follow the            to see the physician. Some offices may advise
recommended treatment or procedure, Member                 you that a fee (not to exceed your copayment)
Services can assist you in the selection of an-            will be charged for missed appointments unless
other Personal Physician.                                  you give 24-hour advance notice or missed the
                                                           appointment because of an emergency situation.
Repeated failures to establish a satisfactory rela-
tionship with a Personal Physician may result in           If you have not selected a Personal Physician for
termination of your coverage, but only after you           any reason, you must contact Member Services
have been given access to other available Per-             at 1-800-334-5847, Monday through Friday, be-
sonal Physicians and have been unsuccessful in             tween 7 a.m. and 7 p.m. to select a Personal
establishing a satisfactory relationship. Any such         Physician to obtain benefits.
termination will take place in accordance with
written procedures established by Blue Shield              Obstetrical/Gynecological (OB/GYN)
and only after written notice to the Member                Physician Services
which describes the unacceptable conduct, pro-             A female Member may arrange for obstetrical
vides the Member with an opportunity to re-                and/or gynecological (OB/GYN) services by an
spond and warns the Member of the possibility              obstetrician/gynecologist or a family practice
of termination.                                            physician who is not her designated Personal
                                                           Physician. A referral from your Personal Physi-
                                                           cian or from the affiliated medical group or IPA
                                                           is not needed. However, the obstetri-

                                                      69
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
cian/gynecologist or family practice physician             from your medical group or IPA. For mental
must be in the same medical group or IPA as                health and substance abuse services, see the
her Personal Physician.                                    Mental Health and Substance Abuse Services
                                                           paragraphs in the How to Use the Plan section
Obstetrical and gynecological services are de-             for information regarding how to access care.
fined as:                                                  The Plan specialist or Plan non-physician health
                                                           care practitioner will provide a complete report
  • Physician services related to prenatal,                to your Personal Physician so that your medical
    perinatal and postnatal (pregnancy) care,              record is complete.
  • Physician services provided to diagnose
    and treat disorders of the female repro-               If there is a question about your diagnosis, plan
    ductive system and genitalia,                          of care, or recommended treatment, including
  • Physician services for treatment of dis-               surgery, or if additional information concerning
    orders of the breast,                                  your condition would be helpful in determining
  • Routine annual gynecological examina-                  the diagnosis and the most appropriate plan of
    tions/annual well-woman examinations.                  treatment, or if the current treatment plan is not
                                                           improving your medical condition, you may ask
It is important to note that services by an obste-         your Personal Physician to refer you to another
trician/gynecologist or a family practice physi-           physician for a second medical opinion. The
cian outside of the Personal Physician’s medical           second opinion will be provided on an expe-
group or IPA without authorization will not be             dited basis, where appropriate. If you are re-
covered under this Plan. Before making the ap-             questing a second opinion about care you
pointment, the Member should call the Member               received from your Personal Physician, the sec-
Services Department at 1-800-334-5847 to con-              ond opinion will be provided by a physician
firm that the obstetrician/gynecologist or family          within the same medical group or IPA as your
practice physician is in the same medical group            Personal Physician. If you are requesting a sec-
or IPA as her Personal Physician.                          ond opinion about care received from a special-
                                                           ist, the second opinion may be provided by any
The OB/GYN physician services are separate                 Plan specialist of the same or equivalent spe-
from the Access+ Specialist feature described              cialty. All second opinion consultations must be
below.                                                     authorized. Your Personal Physician may also
                                                           decide to offer such a referral even if you do not
Referral to Specialty Services and                         request it. State law requires that health plans
Second Medical Opinions                                    disclose to Members, upon request, the time-
Although self-referrals to Plan specialists are al-        lines for responding to a request for a second
lowed through the Access+ Specialist feature               medical opinion. To request a copy of these
described below, Blue Shield encourages you to             timelines, you may call the Member Services
receive specialty services through a referral from         Department at the number listed on the back
your Personal Physician. The Personal Physician            cover of this booklet.
is responsible for coordinating all of your health
care needs and can best direct you for required            If your Personal Physician belongs to a medical
specialty services. Your Personal Physician will           group or IPA that participates as an Access+
generally refer you to a Plan specialist or Plan           Provider, you may also arrange a second opinion
non-physician health care practitioner in the              visit with another physician in the same medical
same medical group or IPA as your Personal                 group or IPA without a referral, subject to the
Physician, but you can be referred outside the             limitations described in the Access+ Specialist
medical group or IPA if the type of specialist or          paragraphs later in this section.
non-physician health care practitioner needed is
not available within your Personal Physician’s             To obtain referral for specialty services, includ-
medical group or IPA. Your Personal Physician              ing lab and x-ray, you must first contact your
will request any necessary prior authorization             Personal Physician. If the Personal Physician de-


                                                      70
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
termines that specialty services are medically             You should cancel any scheduled Access+ Spe-
necessary, the physician will complete a referral          cialist appointment at least 24 hours in advance.
form and request necessary authorization. Your             Unless you give 24-hour advance notice or miss
Personal Physician will designate the Plan pro-            the appointment because of an emergency situa-
vider from whom you will receive services.                 tion, the physician’s office may charge you a fee
When no Plan provider is available to perform              as much as the Access+ Specialist copayment.
the needed service, the Personal Physician will
refer you to a non-Plan provider after obtaining           Note: When you receive a referral from your
authorization. This authorization procedure is             Personal Physician to obtain services from a
handled for you by your Personal Physician.                specialist, you are responsible for the physician
                                                           services copayment.
In certain situations where the Member's medi-
cal condition or disease is life-threatening, de-          For Access+ Specialist visits for mental health
generative, or disabling and requires specialized          and substance abuse services, see the following
medical care over a prolonged period of time,              Mental Health and Substance Abuse Services
the Personal Physician may make a standing re-             paragraphs.
ferral (more than one visit) to an appropriate
specialist.                                                The Access+ Specialist visit includes:

Referral by a Personal Physician does not guar-             • An examination or other consultation
antee coverage for referral services. The eligibil-           provided to you by a medical group Plan
ity provisions, exclusions and limitations will               specialist without referral from your Per-
apply.                                                        sonal Physician;
                                                            • Conventional x-rays such as chest x-rays,
Access+ Specialist                                            abdominal flat plates, and x-rays of
You may arrange an office visit with a Plan spe-              bones to rule out the possibility of frac-
cialist in the same medical group or IPA as your              ture (but does not include any diagnostic
Personal Physician without a referral from your               imaging such as CT, MRI, or bone den-
Personal Physician, subject to the limitations de-            sity measurement);
scribed below. Access+ Specialist office visits             • Laboratory services;
are available only to Members whose Personal                • Diagnostic or treatment procedures
Physicians belong to a medical group or IPA                   which a Plan specialist would regularly
that participates as an Access+ Provider. Refer               provide under a referral from the Per-
to the HMO Physician and Hospital Directory                   sonal Physician.
or call Blue Shield Member Services at 1-800-
334-5847 to determine whether a medical group              An Access+ Specialist visit does not include:
or IPA is an Access+ Provider.
                                                            • Any services which are not covered or
When you arrange for Access+ Specialist visits                which are not medically necessary;
without a referral from your Personal Physician,            • Services provided by a non-Access+
you will be responsible for a $30 copayment for               Provider (such as podiatry and physical
each Access+ Specialist visit. This copayment is              therapy), except for the x-ray and labora-
in addition to any copayments that you may in-                tory services described above;
cur for specific benefits as described in the               • Allergy testing;
Summary of Covered Services. Each follow-up                 • Endoscopic procedures;
office visit with the Plan specialist which is not          • Any diagnostic imaging including CT,
referred or authorized by your Personal Physi-                MRI, or bone density measurement;
cian is a separate Access+ Specialist visit and re-         • Injectables, chemotherapy or other infu-
quires a separate $30 copayment.                              sion drugs, other than vaccines and anti-
                                                              biotics;
                                                            • Infertility services;

                                                      71
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
 • Emergency services;                                  the Definitions section for more information.)
 • Urgent services;                                     All non-emergency mental health and substance
 • Inpatient services, or any services which            abuse services, except for Access+ Specialist
   result in a facility charge, except for rou-         visits, must be arranged through the MHSA.
   tine x-ray and laboratory services;                  Members do not need to arrange for mental
 • Services for which the medical group or              health and substance abuse services through
   IPA routinely allows the Member to self-             their Personal Physician. (See 1. Prior Authori-
   refer without authorization from the                 zation paragraphs below.)
   Personal Physician;
 • OB/GYN services by an obstetrician/                  All mental health and substance abuse services,
   gynecologist or a family practice physi-             except for emergency or urgent services, must
   cian within the same medical group or                be provided by a MHSA Participating Provider.
   IPA as the Personal Physician;                       MHSA Participating Providers are indicated in
                                                        the Blue Shield of California Behavioral Health
 • Internet-based consultations.
                                                        Provider Directory. Members may contact the
                                                        MHSA directly for information on, and to select
NurseHelp 24/7 and LifeReferrals 24/7
                                                        a MHSA Participating Provider by calling 1-866-
NurseHelp 24/7 and LifeReferrals 24/7 pro-
                                                        505-3409. Your Personal Physician may also
grams provide Members with no charge, confi-
                                                        contact the MHSA to obtain information re-
dential telephone support for information,
                                                        garding MHSA Participating Providers for you.
consultations, and referrals for health and psy-
chosocial issues. Members may obtain these ser-         Non-emergency mental health and substance
vices by calling a 24-hour, toll-free telephone         abuse services received from a provider who
number. There is no charge for these services.          does not participate in the MHSA Participating
                                                        Provider network will not be covered, except as
These programs include:
                                                        stated herein, and all charges for these services
                                                        will be the Member’s responsibility. This limita-
NurseHelp 24/7 - Members may call a regis-
                                                        tion does not apply with respect to emergency
tered nurse toll free via 1-877-304-0504, 24
                                                        services. In addition, when no MHSA Partici-
hours a day, to receive confidential advice and
                                                        pating Provider is available to perform the
information about minor illnesses and injuries,
                                                        needed service, the MHSA will refer you to a
chronic conditions, fitness, nutrition and other
                                                        non-Plan provider and authorize services to be
health-related topics.
                                                        received.
Psychosocial support through LifeReferrals
                                                        For complete information regarding benefits for
24/7 - Members may call 1-800-985-2405 on a
                                                        mental health and substance abuse services, see
24-hour basis for confidential psychosocial sup-
                                                        Q. Inpatient Mental Health and Substance
port services. Professional counselors will pro-
                                                        Abuse Services and R. Outpatient Mental
vide support through assessment, referrals and
                                                        Health and Substance Abuse Services in the
counseling. Note: See the following Mental
                                                        Benefit Descriptions section.
Health and Substance Abuse Services para-
graphs for important information concerning
                                                        1. Prior Authorization
this feature.
                                                            All non-emergency mental health and sub-
Mental Health and Substance Abuse                           stance abuse services must be prior author-
Services                                                    ized by the MHSA. For prior authorization
Blue Shield of California has contracted with a             of mental health and substance abuse ser-
Mental Health Service Administrator (MHSA)                  vices, the Member should contact the
to underwrite and deliver all mental health and             MHSA at 1-866-505-3409.
substance abuse services through a unique net-
work of mental health Participating Providers.              Failure to receive prior authorization for
(See Mental Health Service Administrator under              mental health and substance abuse services

                                                   72
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
   as described, except for emergency and ur-             3. Psychosocial Support through LifeReferrals
   gent services, will result in the Member be-              24/7
   ing totally responsible for all costs for these
   services.                                                 Notwithstanding the benefits provided un-
                                                             der R. Outpatient Mental Health and Sub-
   Note: The MHSA will render a decision on                  stance Abuse Services, the Member also
   all requests for prior authorization of ser-              may call 1--800-985-2405 on a 24-hour basis
   vices as follows:                                         for confidential psychosocial support ser-
                                                             vices. Professional counselors will provide
   • for urgent services, as soon as possible                support through assessment, referrals and
     to accommodate the Member’s condi-                      counseling.
     tion not to exceed 72 hours from re-
     ceipt of the request;                                   In California, support may include, as ap-
   • for other services, within 5 business                   propriate, a referral to a counselor for a
     days from receipt of the request. The                   maximum of three no charge, face-to-face
     treating provider will be notified of the               visits within a 6-month period.
     decision within 24 hours followed by
     written notice to the provider and                      In the event that the services required of a
     Member within 2 business days of the                    Member are most appropriately provided by
     decision.                                               a psychiatrist or the condition is not likely to
                                                             be resolved in a brief treatment regimen, the
2. Access+ Specialist Visits for Mental Health               Member will be referred to the MHSA in-
   and Substance Abuse Services                              take line to access his mental health and
                                                             substance abuse services which are de-
   The Access+ Specialist feature is available               scribed under R. Outpatient Mental Health
   for all mental health and substance abuse                 and Substance Abuse Services.
   services except for psychological testing and
   written evaluation which are not covered               Emergency Services
   under this benefit.                                    What is an Emergency?
                                                          An emergency means an unexpected medical
   The Member may arrange for an Access+                  condition manifesting itself by acute symptoms
   Specialist office visit for mental health and          of sufficient severity (including severe pain)
   substance abuse services without a referral            such that a layperson who possesses an average
   from the MHSA, as long as the provider is a            knowledge of health and medicine could rea-
   MHSA Participating Provider. Refer to the              sonably assume that the absence of immediate
   Blue Shield of California Behavioral Health            medical attention could be expected to result in
   Provider Directory or call the MHSA at                 any of the following: (1) placing the Member’s
   1-866-505-3409 to determine MHSA Par-                  health in serious jeopardy, (2) serious impair-
   ticipating Providers. Members will be re-              ment to bodily functions, (3) serious dysfunc-
   sponsible for a $30 copayment for each                 tion of any bodily organ or part. If you receive
   Access+ Specialist visit for mental health             non-authorized services in a situation that Blue
   and substance abuse services. Each follow-             Shield determines was not a situation in which a
   up office visit for mental health and sub-             reasonable person would believe that an emer-
   stance abuse services which is not referred            gency condition existed, you will be responsible
   or authorized by the MHSA is a separate                for the costs of those services.
   Access+ Specialist visit and requires a sepa-
   rate $30 copayment.                                    Members who reasonably believe that they have
                                                          an emergency medical or mental health condi-
                                                          tion which requires an emergency response are
                                                          encouraged to appropriately use the “911”
                                                          emergency response system where available.

                                                     73
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
What to do in case of Emergency:                             gent care clinic in your Personal Physician ser-
Life Threatening                                             vice area.
    Obtain care immediately.
                                                             Outside of California or the United States
    Contact your Personal Physician no later                 The Blue Shield Access+ HMO provides cover-
    than 24 hours after the onset of the emer-               age for you and your family for your urgent ser-
    gency, or as soon as it is medically possible            vice needs when you or your family are
    for the Member to provide notice.                        temporarily traveling outside of California. You
                                                             can receive urgent care services from any pro-
Non-Life Threatening                                         vider; however, using the BlueCard® Program,
    Consult your Personal Physician, anytime                 described below, can be more cost-effective and
    day or night, regardless of where you are                eliminate the need for you to pay for the services
    prior to receiving medical care.                         when they are rendered and submit a claim for re-
                                                             imbursement.
Follow-Up Care
                                                             Through the BlueCard Program, you can access
    Follow-up care, which is any care provided
                                                             urgent care services across the country and
    after the initial emergency room visit, must
                                                             around the world. While traveling within the
    be provided or authorized by your Personal
                                                             United States, you can locate a BlueCard Pro-
    Physician.
                                                             gram participating provider any time by calling
For a complete description of the Emergency                  1-800-810-BLUE (2583) or going on-line at
Services benefit and applicable copayments, see              http://www.bcbs.com and selecting the “Find a
I. Emergency Services in the Benefit Descrip-                Doctor or Hospital” tab. If you are traveling out-
tions section.                                               side of the United States, you can call 1-804-673-
                                                             1177 collect 24 hours a day to locate a BlueCard
Urgent Services                                              Worldwide® Network provider.
The Blue Shield Access+ HMO provides cover-                  Out-of-area follow-up care is covered and may
age for you and your family for your urgent ser-             be received through the BlueCard Program par-
vice needs when you or your family are                       ticipating provider network or from any pro-
temporarily traveling outside of your Personal               vider. However, authorization by Blue Shield is
Physician service area.                                      required for more than two out-of-area follow-
                                                             up care outpatient visits or for care that involves
Urgent services are defined in Section 3, under
                                                             a surgical or other procedure or inpatient stay.
Definitions. Out-of-area follow-up care is de-
                                                             The Blue Shield Access+ HMO may direct the
fined in Section 3, under Definitions.
                                                             patient to receive the additional follow-up ser-
(Urgent care) While in your Personal Physi-                  vices from the Personal Physician.
cian Service Area
                                                             If services are not received from a BlueCard
If you require urgent care for a condition that              Program participating provider, you may be re-
could reasonably be treated in your Personal                 quired to pay the provider for the entire cost of
Physician’s office or in an urgent care clinic (i.e.,        the service and submit a claim to the Blue Shield
care for a condition that is not such that the ab-           Access+ HMO. Claims for urgent services and
sence of immediate medical attention could rea-              out-of-area follow-up care rendered outside of
sonably be expected to result in placing your                California and not provided by a BlueCard Pro-
health in serious jeopardy, serious impairment to            gram participating provider will be reviewed ret-
bodily functions, or serious dysfunction of any              rospectively for coverage.
bodily organ or part), you must first call your
Personal Physician. However, you may go di-                  Under the BlueCard Program, when you obtain
rectly to an urgent care clinic when your as-                health care services outside of California, the
signed medical group or IPA has provided you
with instructions for obtaining care from an ur-

                                                        74
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
amount you pay, if not subject to a flat dollar           Within California
copayment, is calculated on the lower of:                 If you are temporarily traveling within Califor-
                                                          nia, but are outside of your Personal Physician
1. The allowed charges for your covered ser-              service area, if possible you should call Blue
   vices, or                                              Shield Member Services at 1-800-334-5847 for
                                                          assistance in receiving urgent services through a
2. The negotiated price that the local Blue               Blue Shield of California Plan provider. You may
   Cross and/or Blue Shield plan passes on to             also locate a Plan provider by visiting our web site
   us.                                                    at http://www.blueshieldca.com. However, you
                                                          are not required to use a Blue Shield of California
Often, this "negotiated price" will consist of a          Plan provider to receive urgent services; you may
simple discount which reflects the actual price           use any provider.
paid by the local Blue Cross and/or Blue Shield
plan. But sometimes it is an estimated price that         Follow-up care is also covered through a Blue
factors into the actual price expected settle-            Shield of California Plan provider and may also
ments, withholds, any other contingent payment            be received from any provider. However, when
arrangements and non-claims transactions with             outside your Personal Physician service area au-
your health care provider or with a specified             thorization by Blue Shield is required for more
group of providers. The negotiated price may              than two out-of-area follow-up care outpatient
also be billed charges reduced to reflect an aver-        visits or for care that involves a surgical or other
age expected savings with your health care pro-           procedure or inpatient stay. The Blue Shield Ac-
vider or with a specified group of providers.             cess+ HMO may direct the patient to receive the
The price that reflects average savings may re-           additional follow-up services from the Personal
sult in greater variation (more or less) from the         Physician.
actual price paid than will the estimated price.
The negotiated price will also be adjusted in the         If services are not received from a Blue Shield
future to correct for over- or underestimation of         of California Plan provider, you may be required
past prices. However, the amount you pay is               to pay the provider for the entire cost of the
considered a final price.                                 service and submit a claim to the Blue Shield
                                                          Access+ HMO. Claims for urgent services ob-
Statutes in a small number of states may require          tained outside of your Personal Physician ser-
the local Blue Cross and/or Blue Shield plan to           vice area within California will be reviewed
use a basis for calculating Member liability for          retrospectively for coverage.
covered services that does not reflect the entire
savings realized, or expected to be realized, on a        When you receive covered urgent services out-
particular claim or to add a surcharge. Should            side your Personal Physician service area within
any state statutes mandate Member liability cal-          California, the amount you pay, if not subject to
culation methods that differ from the usual               a flat dollar copayment, is calculated on Blue
BlueCard Program method noted above or re-                Shield’s allowed charges.
quire a surcharge, Blue Shield of California
would then calculate your liability for any cov-          See J. Urgent Services in the Benefit Descrip-
ered health care services in accordance with the          tions section for benefit description, applicable
applicable state statute in effect at the time you        copayment information, and information on
received your care.                                       payment responsibility and claims submission.

For any other providers, the amount you pay, if           Inpatient, Home Health Care
not subject to a flat dollar copayment, is calcu-         and Other Services
lated on the provider’s billed charges for your           The Personal Physician is responsible for ob-
covered services.                                         taining prior authorization before you can be
                                                          admitted to the hospital or a skilled nursing fa-
                                                          cility, including subacute care admissions, except

                                                     75
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
for mental health and substance abuse services           from MHSA Participating Providers. Hospice
which are described in the previous Mental               services must be received from a participating
Health and Substance Abuse Services section.             hospice agency.
The Personal Physician is responsible for ob-
taining prior authorization before you can re-           If your condition requires services which are
ceive home health care and certain other                 available from the Plan, payment for services
services or before you can be admitted into a            rendered by non-Plan providers will not be con-
hospice program through a participating hospice          sidered unless the medical condition requires
agency. If the Personal Physician determines             emergency or urgent services.
that you should receive any of these services, he
or she will request authorization. Your Personal         You are responsible for paying a minimum
Physician will arrange for your admission to the         charge (copayment) to the physician or provider
hospital, skilled nursing facility, or a hospice         of services at the time you receive services. The
program through a participating hospice agency,          specific copayments, as applicable, are listed af-
as well as for the provision of home health care         ter the benefit description. There are no de-
and other services.                                      ductibles to be met.

For hospital admissions for mastectomies or              Limitation of Liability
lymph node dissections, the length of hospital           Members shall not be responsible to Plan provid-
stays will be determined solely by the Member’s          ers for payment for services if they are a benefit
physician in consultation with the Member. For           of the Plan. When covered services are rendered
information regarding length of stay for mater-          by a Plan provider, the Member is responsible
nity or maternity-related services, see F. Preg-         only for the applicable copayments, except as set
nancy and Maternity Care, for information                forth in the Third Party Recovery Process and the
relative to the Newborns’ and Mothers’ Health            Member’s Responsibility section. Members are
Protection Act.                                          responsible for the full charges for any non-
                                                         covered services they obtain.
Liability of Member for Payment
It is important to note that all services except         Member Identification Card
for those meeting the emergency and out of ser-          You will receive your Blue Shield Access+
vice area urgent services requirements, Access+          HMO identification card after enrollment. If
Specialist visits, hospice program services re-          you do not receive your identification card or if
ceived from a participating hospice agency after         you need to obtain medical or prescription ser-
the Member has been accepted into the hospice            vices before your card arrives, contact the Blue
program, OB/GYN services by an obstetri-                 Shield Member Services Department so that
cian/gynecologist or a family practice physician         they can coordinate your care and direct your
who is in the same medical group or IPA as the           Personal Physician or pharmacy.
Personal Physician, and all mental health and
substance abuse services, must have prior au-            Member Services Department
thorization by the Personal Physician, medical           For all services other than mental health and
group or IPA. The Member will be responsible             substance abuse
for payment of services that are not authorized          If you have a question about services, providers,
or those that are not an emergency or covered            benefits, how to use this plan, or concerns re-
out of service area urgent service procedures.           garding the quality of care or access to care that
(See the previous Urgent Services paragraphs             you have experienced, you should call the Blue
for information on receiving urgent services out         Shield Member Services Department at 1-800-
of the service area but within California.) Mem-         334-5847. The hearing impaired may contact
bers must obtain services from the Plan provid-          Blue Shield’s Member Services Department
ers that are authorized by their Personal                through Blue Shield’s toll-free TTY number,
Physician, medical group or IPA and, for all             1-800-241-1823. Member Services can answer
mental health and substance abuse services,              many questions over the telephone.

                                                    76
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Expedited Decision                                        Member and physician as soon as possible to
Blue Shield of California has established a pro-          accommodate the Member’s condition not to
cedure for our Members to request an expedited            exceed 72 hours following the receipt of the re-
decision (including those regarding grievances).          quest. An expedited decision may involve ad-
A Member, physician, or representative of a               missions, continued stay or other health care
Member may request an expedited decision                  services. If you would like additional informa-
when the routine decision making process might            tion regarding the expedited decision process, or
seriously jeopardize the life or health of a Mem-         if you believe your particular situation qualifies
ber, or when the Member is experiencing severe            for an expedited decision, please contact the
pain. Blue Shield shall make a decision and no-           MHSA at the number listed above.
tify the Member and physician as soon as possi-
ble to accommodate the Member’s condition                 For information on additional rights, see the
not to exceed 72 hours following the receipt of           Grievance Process section.
the request. An expedited decision may involve
admissions, continued stay or other health care           Rates for Supplement to Original
services. If you would like additional informa-           Medicare Plan
tion regarding the expedited decision process, or         Cost of the Program
if you believe your particular situation qualifies        Type of Enrollment                                Monthly Rate
for an expedited decision, please contact our
Member Services Department at 1-800-334-                  Employee only ................................................ $337.88
5847.                                                     Employee and one dependent...................... $675.76
                                                          Employee and two or more dependents .. $1013.64
For all mental health and substance abuse
services                                                  State Employees and Annuitants
For all mental health and substance abuse ser-            The rates shown above are effective January 1,
vices Blue Shield of California has contracted            2011, and will be reduced by the amount the
with the Plan’s Mental Health Service Adminis-            State of California contributes toward the cost
trator (MHSA). The MHSA should be contacted               of your health benefit plan. These contribution
for questions about mental health and substance           amounts are subject to change as a result of col-
abuse services, MHSA Participating Providers,             lective bargaining agreements or legislative ac-
or mental health and substance abuse benefits.            tion. Any such change will be accomplished by
You may contact the MHSA at the telephone                 the State Controller or affected retirement sys-
number or address which appear below:                     tem without any action on your part. For cur-
                                                          rent contribution information, contact your
                1-877-263-9952                            retirement system health benefits officer.
          Blue Shield of California
     Mental Health Service Administrator                  Contracting Agency Employees and
    3111 Camino Del Rio North, Suite 600                  Annuitants
           San Diego, CA 92108                            The rates shown above are effective January 1,
                                                          2011, and will be reduced by the amount your
The MHSA can answer many questions over the
                                                          contracting agency contributes toward the cost
telephone.
                                                          of your health benefit plan. This amount varies
The MHSA has established a procedure for our              among public agencies. For assistance on calcu-
Members to request an expedited decision. A               lating your net contribution, contact your agency
Member, physician, or representative of a Mem-            or retirement system health benefits officer.
ber may request an expedited decision when the
routine decision making process might seriously           Rate Change
jeopardize the life or health of a Member, or             The plan rates may be changed as of January 1,
when the Member is experiencing severe pain.              2012, following at least 60 days’ written notice
The MHSA shall make a decision and notify the             to the Board prior to such change.


                                                     77
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Benefit Descriptions                                        b. General nursing care, and special duty
For additional information concerning covered                  nursing when medically necessary;
benefits, contact the Health Insurance Counsel-
ing and Advocacy Program (HICAP) or                         c. Meals and special diets when medically
CalPERS. HICAP provides health insurance                       necessary;
counseling for California senior citizens. Call the         d. Intensive care services and units;
HICAP toll-free telephone number, 1-800-434-
0222, for a referral to your local HICAP office.            e. Operating room, special treatment
HICAP is a service provided free of charge by                  rooms, delivery room, newborn nursery
the State of California.                                       and related facilities;
The Plan benefits available to you are listed in            f. Hospital ancillary services including di-
this section. The copayments for these services,               agnostic laboratory, x-ray services and
if applicable, follow each benefit description.                therapy services;

The following are the basic health care services            g. Drugs, medications, biologicals, and
covered by the Blue Shield Access+ HMO                         oxygen administered in the hospital, and
without charge to the Member, except for co-                   up to 3 days’ supply of drugs supplied
payments where noted, and as set forth in the                  upon discharge by the Plan physician for
Third Party Recovery Process and the Member’s                  the purpose of transition from the hospi-
Responsibility section. These services are cov-                tal to home;
ered when medically necessary, and when pro-
vided by the Member’s Personal Physician or                 h. Surgical and anesthetic supplies, dress-
other Plan provider or authorized as described                 ings and cast materials, surgically im-
herein, or received according to the provisions                planted devices and prostheses, other
described under Obstetrical/Gynecological                      medical supplies and medical appliances
(OB/GYN) Physician Services, Access+ Spe-                      and equipment administered in hospital;
cialist, and Mental Health and Substance Abuse              i. Processing, storage and administration of
Services. Coverage for these services is subject               blood, and blood products (plasma), in
to all terms, conditions, limitations and exclu-               inpatient and outpatient settings. In-
sions of the Agreement, to any conditions or                   cludes the storage and collection of
limitations set forth in the benefit descriptions              autologous blood;
below, and to the Exclusions and Limitations
set forth in this booklet.                                  j. Radiation therapy, chemotherapy and re-
                                                               nal dialysis;
Except as specifically provided herein, services
are covered only when rendered by an individual             k. Respiratory therapy and other diagnostic,
or entity that is licensed or certified by the state           therapeutic and rehabilitation services as
to provide health care services and is operating               appropriate;
within the scope of that license or certification.
                                                            l. Coordinated discharge planning, includ-
A. Hospital Services                                           ing the planning of such continuing care
The following hospital services customarily fur-               as may be necessary;
nished by a hospital will be covered when medi-
                                                            m. Inpatient services, including general an-
cally necessary and authorized.
                                                               esthesia and associated facility charges, in
                                                               connection with dental procedures when
1. Inpatient hospital services include:
                                                               hospitalization is required because of an
    a. Semi-private room and board, unless a                   underlying medical condition and clinical
       private room is medically necessary;                    status or because of the severity of the
                                                               dental procedure. Includes enrollees un-
                                                               der the age of 7 and the developmentally

                                                       78
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
       disabled who meet these criteria. Ex-                   counseling, and OB/GYN services from an
       cludes services of dentist or oral surgeon;             obstetrician/gynecologist or a family prac-
                                                               tice physician who is within the same medi-
    n. Subacute care;                                          cal group or IPA as the Personal Physician.
                                                               Benefits are also provided for asthma self-
    o. Medically necessary inpatient substance
                                                               management training and education to en-
       abuse detoxification services required to
                                                               able a Member to properly use asthma-
       treat potentially life-threatening symp-
                                                               related medication and equipment such as
       toms of acute toxicity or acute with-
                                                               inhalers, spacers, nebulizers and peak flow
       drawal are covered when a covered
                                                               monitors.
       Member is admitted through the emer-
       gency room or when medically necessary                      Copayment: $10 per visit.
       inpatient substance abuse detoxification
       is prior authorized;                                 2. Allergy Testing and Treatment
    p. Rehabilitation when furnished by the                    Office visits for the purpose of allergy test-
       hospital and authorized.                                ing and treatment, including injectables and
See Section O. for inpatient hospital services                 serum.
provided under the “Hospice Program Services”
                                                                   Copayment: $10 per visit or treatment.
benefit.
                                                            3. Inpatient Medical and Surgical Services
        Copayment: No charge.

2. Outpatient hospital services include:                       Physicians’ services in a hospital or skilled
                                                               nursing facility for examination, diagnosis,
    a. Services and supplies for treatment or                  treatment, and consultation, including the
       surgery in an outpatient hospital setting               services of a surgeon, assistant surgeon, an-
       or ambulatory surgery center;                           esthesiologist, pathologist, and radiologist.
                                                               Inpatient physician services are covered only
    b. Outpatient services, including general                  when hospital and skilled nursing facility
       anesthesia and associated facility charges,             services are also covered.
       in connection with dental procedures
       when the use of a hospital or outpatient                    Copayment: No charge.
       facility is required because of an underly-
       ing medical condition and clinical status            4. Medically necessary home visits by Plan
       or because of the severity of the dental                physician
       procedure. Includes enrollees under the
                                                                   Copayment: $10 per visit.
       age of 7 and the developmentally dis-
       abled who meet these criteria. Excludes
                                                            5. Treatment of physical complications of a
       services of dentist or oral surgeon.
                                                               mastectomy, including lymphedemas
        Copayment: No charge.
                                                                   Copayment: $10 per visit.
B. Physician Services (Other Than for
                                                            6. Internet-Based Consultations. Medically
   Mental Health and Substance Abuse
                                                               necessary consultations with Internet Ready
   Services)                                                   Physicians via Blue Shield approved Internet
1. Physician Office Visits                                     portal. Internet-based consultations are
                                                               available only to Members whose Personal
    Office visits for examination, diagnosis and               Physicians (or other physicians to whom
    treatment of a medical condition, disease or               you have been referred for care within your
    injury, including specialist office visits, sec-           Personal Physician’s medical group or IPA)
    ond opinion or other consultations, diabetic

                                                       79
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    have agreed to provide Internet-based con-             E. Durable Medical Equipment,
    sultations via the Blue Shield approved                   Prostheses and Orthoses and
    Internet portal (“Internet Ready”). Internet-             Other Services
    based consultations for mental health and              Medically necessary durable medical equipment,
    substance abuse conditions are not covered.            prostheses and orthoses for activities of daily
    Refer to the On-Line Physician Directory to            living, and supplies needed to operate durable
    determine whether your physician is Inter-             medical equipment; oxygen and oxygen equip-
    net Ready and how to initiate an Internet-             ment and its administration; blood glucose
    based consultation. This information can be            monitors as medically appropriate for insulin
    accessed at http://www.blueshieldca.com.               dependent, non-insulin dependent and gesta-
                                                           tional diabetes; apnea monitors; and ostomy and
        Copayment: $10 per consultation.
                                                           medical supplies to support and maintain gastro-
                                                           intestinal, bladder or respiratory function are
C. Preventive Health Services                              covered. When authorized as durable medical
1. Preventive health services, as defined, when            equipment, other covered items include peak
   rendered by a physician are covered.                    flow monitor for self-management of asthma,
                                                           the glucose monitor for self-management of
        Copayment: No charge.
                                                           diabetes, apnea monitors for management of
2. Eye refraction to determine the need for                newborn apnea, and the home prothrombin
   corrective lenses for all Members upon re-              monitor for specific conditions as determined
   ferral by the Personal Physician.                       by Blue Shield. Benefits are provided at the
                                                           most cost-effective level of care that is consis-
        Copayment: $10 per visit. (Limited to              tent with professionally recognized standard of
        one visit per calendar year, for Members           practice. If there are two or more professionally
        aged 18 and over. No limit on number of            recognized items equally appropriate for a con-
        visits for Members under age 18.)                  dition, benefits will be based on the most cost-
                                                           effective item.
D. Diagnostic X-ray/Lab Services
1. X-ray, Laboratory, Major Diagnostic Ser-                1. Durable Medical Equipment
   vices. All outpatient diagnostic x-ray and
   clinical laboratory tests and services, includ-             a. Replacement of durable medical equip-
   ing diagnostic imaging, electrocardiograms,                    ment is covered only when it no longer
   and diagnostic clinical isotope services.                      meets the clinical needs of the patient or
                                                                  has exceeded the expected lifetime of the
2. Genetic Testing and Diagnostic Procedures.                     item.*
   Genetic testing for certain conditions when                    *This does not apply to the medically
   the Member has risk factors such as family                     necessary replacement of nebulizers, face
   history or specific symptoms. The testing                      masks and tubing, and peak flow moni-
   must be expected to lead to increased or al-                   tors for the management and treatment
   tered monitoring for early detection of dis-                   of asthma. (See Section P. for benefits
   ease, a treatment plan or other therapeutic                    for asthma inhalers and inhaler spacers.)
   intervention and determined to be medically
   necessary and appropriate in accordance                     b. Medically necessary repairs and mainte-
   with Blue Shield of California medical pol-                    nance of durable medical equipment, as
   icy.                                                           authorized by Plan provider. Repair is
                                                                  covered unless necessitated by misuse or
See Section F. for genetic testing for prenatal di-               loss.
agnosis of genetic disorders of the fetus.
                                                               c. Rental charges for durable medical
        Copayment: No charge.                                     equipment in excess of the purchase
                                                                  price are not covered.

                                                      80
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
   d. Benefits do not include environmental                        traocular lens, one pair of conven-
      control equipment or generators. No                          tional eyeglasses or contact lenses;
      benefits are provided for backup or al-
      ternate items.                                            8) Artificial limbs and eyes.

See Section V. for devices, equipment and sup-               b. Routine maintenance is not covered.
plies for the management and treatment of dia-
                                                             c. Benefits do not include wigs for any rea-
betes.
                                                                son, self-help/educational devices or any
If you are enrolled in a hospice program                        type of speech or language assistance de-
through a participating hospice agency, medical                 vices, except as specifically provided
equipment and supplies that are reasonable and                  above. See the Exclusions and Limita-
necessary for the palliation and management of                  tions section for a listing of excluded
terminal illness and related conditions are pro-                speech and language assistance devices.
vided by the hospice agency. For information                    No benefits are provided for backup or
see Section O.                                                  alternate items.
                                                             For surgically implanted and other pros-
2. Prostheses
                                                             thetic devices (including prosthetic bras)
                                                             provided to restore and achieve symmetry
   a. Medically necessary prostheses for activi-
                                                             incident to a mastectomy, see Section W.
      ties of daily living, including the follow-
                                                             Surgically implanted prostheses including,
      ing:
                                                             but not limited to, Blom-Singer and artificial
       1) Supplies necessary for the operation               larynx prostheses for speech following a
          of prostheses;                                     laryngectomy are covered as a surgical pro-
                                                             fessional benefit.
       2) Initial fitting and replacement after
          the expected life of the item;                  3. Orthoses

       3) Repairs, even if due to damage;                    a. Medically necessary orthoses for activi-
                                                                ties of daily living, including the follow-
       4) Surgically implanted prostheses in-                   ing:
          cluding, but not limited to, Blom-
          Singer and artificial larynx prostheses               1) Special footwear required for foot
          for speech following a laryngectomy;                     disfigurement which includes but is
                                                                   not limited to foot disfigurement
       5) Prosthetic devices used to restore a                     from cerebral palsy, arthritis, polio,
          method of speaking following laryn-                      spina bifida, diabetes or by accident
          gectomy, including initial and subse-                    or developmental disability;
          quent prosthetic devices and
          installation accessories. This does not               2) Medically necessary functional foot
          include electronic voice producing                       orthoses that are custom made rigid
          machines;                                                inserts for shoes, ordered by a physi-
                                                                   cian or podiatrist, and used to treat
       6) Cochlear implants;                                       mechanical problems of the foot, an-
                                                                   kle or leg by preventing abnormal
       7) Contact lenses if medically necessary
                                                                   motion and positioning when im-
          to treat eye conditions such as kerato-
                                                                   provement has not occurred with a
          conus, keratitis sicca or aphakia. Cata-
                                                                   trial of strapping or an over-the-
          ract spectacles or intraocular lenses
                                                                   counter stabilizing device;
          that replace the natural lens of the eye
          after cataract surgery. If medically                  3) Medically necessary knee braces for
          necessary with the insertion of the in-                  post-operative rehabilitation follow-

                                                     81
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
          ing ligament surgery, instability due to        3. Includes providing coverage for all testing
          injury, and to reduce pain and insta-              recommended by the California Newborn
          bility for patients with osteoarthritis.           Screening Program and for participating in
                                                             the statewide prenatal testing program, ad-
   b. Benefits for medically necessary orthoses              ministered by the State Department of
      are provided at the most cost-effective                Health Services, known as the Expanded
      level of care that is consistent with pro-             Alpha Feto Protein Program.
      fessionally recognized standards of prac-
      tice. If there are two or more                              Copayment: No charge.
      professionally recognized appliances
      equally appropriate for a condition, the            The Newborns' and Mothers' Health Protection
      Plan will provide benefits based on the             Act requires group health plans to provide a
      most cost-effective appliance. Routine              minimum hospital stay for the mother and new-
      maintenance is not covered. No benefits             born child of 48 hours after a normal, vaginal
      are provided for backup or alternate                delivery and 96 hours after a C-section unless
      items.                                              the attending physician, in consultation with the
                                                          mother, determines a shorter hospital length of
   c. Benefits are provided for orthotic de-              stay is adequate.
      vices for maintaining normal activities of
      daily living only. No benefits are pro-             If the hospital stay is less than 48 hours after a
      vided for orthotic devices such as knee             normal, vaginal delivery or less than 96 hours af-
      braces intended to provide additional               ter a C-section, a follow-up visit for the mother
      support for recreational or sports activi-          and newborn within 48 hours of discharge is
      ties or for orthopedic shoes and other              covered when prescribed by the treating physi-
      supportive devices for the feet.                    cian. This visit shall be provided by a licensed
                                                          health care provider whose scope of practice in-
       Copayment: No charge.
                                                          cludes postpartum and newborn care. The treat-
                                                          ing physician, in consultation with the mother,
See Section V. for devices, equipment and sup-
                                                          shall determine whether this visit shall occur at
plies for the management and treatment of dia-
                                                          home, the contracted facility, or the physician’s
betes.
                                                          office.
F. Pregnancy and Maternity Care
                                                          G. Family Planning and Infertility
The following pregnancy and maternity care is
                                                             Services
covered subject to the General Exclusions and
Limitations.                                              1. Family Planning Counseling

1. Prenatal and Postnatal Physician Office Vis-                   Copayment: No charge.
   its
                                                          2. Infertility Services. Infertility services (in-
   See Section D. for information on coverage                cluding artificial insemination), except as ex-
   of other genetic testing and diagnostic pro-              cluded in the General Exclusions and
   cedures.                                                  Limitations, including professional, hospital,
                                                             ambulatory surgery center, ancillary services
2. Inpatient Hospital and Professional Ser-                  and injectable drugs administered or pre-
   vices. Hospital and Professional services for             scribed by the provider to diagnose and
   the purposes of a normal delivery, C-                     treat the cause of infertility.
   section, complications or medical conditions
                                                                  Copayment: 50% of allowed charges
   arising from pregnancy or resulting child-
                                                                  for all services.
   birth.




                                                     82
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
3. Sterilization Procedures, including Tubal                admission and the use of the ambulance is
   Ligation and Vasectomy                                   authorized.

       Copayment: See applicable copay-                         Copayment: No charge.
       ments for Physician Services and Hos-
       pital Services.                                   I. Emergency Services
                                                         An emergency means an unexpected medical
4. Elective Abortion                                     condition manifesting itself by acute symptoms
                                                         of sufficient severity (including severe pain)
       Copayment: See applicable copay-                  such that a layperson who possesses an average
       ments for Physician Services and Hos-             knowledge of health and medicine could rea-
       pital Services.
                                                         sonably assume that the absence of immediate
                                                         medical attention could be expected to result in
5. Contraceptive Devices and Fitting
                                                         any of the following: (1) placing the Member’s
       Copayment: $10 per visit; $5 per device           health in serious jeopardy, (2) serious impair-
       in conjunction with office visit. Dia-            ment to bodily functions, (3) serious dysfunc-
       phragms also covered under Section                tion of any bodily organ or part. If you receive
       P.; see applicable copayments for Pre-            services in a situation that the Blue Shield Ac-
       scription Drugs.                                  cess+ HMO determines was not a situation in
                                                         which a reasonable person would believe that an
6. Oral Contraceptives                                   emergency condition existed, you will be re-
                                                         sponsible for the costs of those services.
       Copayment: See applicable copay-
       ments for Prescription Drugs.                     1. Members who reasonably believe that they
                                                            have an emergency medical or mental health
7. Injectable Contraceptives, excluding inter-              condition which requires an emergency re-
   nally implanted time release contraceptives              sponse are encouraged to appropriately use
                                                            the “911” emergency response system
       Copayment: $10 per visit; $15 for each               where available. The Member should notify
       injection.                                           the Personal Physician or the MHSA by
                                                            phone within 24 hours of the commence-
H. Ambulance Services                                       ment of the emergency services, or as soon
The Plan will pay for ambulance services as fol-            as it is medically possible for the Member to
lows:                                                       provide notice. Failure to provide notice as
                                                            stated will result in the services not being
1. Emergency Ambulance Services                             covered.
   For transportation to the nearest hospital            2. Whenever possible, go to the emergency
   which can provide such emergency care                    room of your nearest Blue Shield Access+
   only if a reasonable person would have be-               HMO hospital for medical emergencies. A
   lieved that the medical condition was an                 listing of Blue Shield Access+ HMO hospi-
   emergency medical condition which re-                    tals is available in your HMO Physician and
   quired ambulance services, as described in               Hospital Directory.
   Section I.
                                                         3. The services will be reviewed retrospectively
2. Non-Emergency Ambulance Services                         by the Plan to determine whether the ser-
                                                            vices were for a medical condition for which
   Medically necessary ambulance services to                a reasonable person would have believed
   transfer the Member from a non-Plan hos-                 that they had an emergency medical condi-
   pital to a Plan hospital, between Plan facili-           tion.
   ties, or from facility to home when in
   connection with authorized confinement/

                                                    83
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
       Copayment: $50 per visit in the hospi-                    payment is requested. If the claim is not
       tal emergency room. (Emergency ser-                       submitted within this period, the Plan
       vices copayment does not apply if                         will not pay for those emergency ser-
       Member is admitted directly to hospi-                     vices, unless the claim was submitted as
       tal as an inpatient from emergency                        soon as reasonably possible as deter-
       room or kept for observation and hos-                     mined by the Plan. If the services are not
       pital bills for an emergency room ob-                     pre-authorized, the Plan will review the
       servation visit.)                                         claim retrospectively for coverage. If the
                                                                 Plan determines that these services re-
4. Continuing or Follow-up Treatment. If you
                                                                 ceived were for a medical condition for
   receive emergency services from a hospital
                                                                 which a reasonable person would not
   which is a non-Plan hospital, follow-up care
                                                                 reasonably believe that an emergency
   must be authorized by Blue Shield or it may
                                                                 condition existed and would not other-
   not be covered. If, once your emergency
                                                                 wise have been authorized, and, there-
   medical condition is stabilized, and your
                                                                 fore, are not covered, it will notify the
   treating health care provider at the non-Plan
                                                                 Member of that determination. The Plan
   hospital believes that you require additional
                                                                 will notify the Member of its determina-
   medically necessary hospital services, the
                                                                 tion within 30 days from receipt of the
   non-Plan hospital must contact Blue Shield
                                                                 claim. In the event covered medical
   to obtain timely authorization. Blue Shield
                                                                 transportation services are obtained in
   may authorize continued medically neces-
                                                                 such an emergency situation, the Blue
   sary hospital services by the non-Plan hospi-
                                                                 Shield Access+ HMO shall pay the
   tal. If Blue Shield determines that you may
                                                                 medical transportation provider directly.
   be safely transferred to a hospital that is
   contracted with the Plan and you refuse to                b. Out-of-Area Urgent Services. If out-of-
   consent to the transfer, the non-Plan hospi-                 area urgent services were received from a
   tal must provide you with written notice                     non-participating BlueCard Program
   that you will be financially responsible for                 provider, you must submit a complete
   100% of the cost for services provided to                    claim with the urgent service record for
   you once your emergency condition is sta-                    payment to the Plan, within 1 year after
   ble. Also, if the non-Plan hospital is unable                the first provision of urgent services for
   to determine the contact information at                      which payment is requested. If the claim
   Blue Shield in order to request prior au-                    is not submitted within this period, the
   thorization, the non-Plan hospital may bill                  Plan will not pay for those urgent ser-
   you for such services. If you believe you are                vices, unless the claim was submitted as
   improperly billed for services you receive                   soon as reasonably possible as deter-
   from a non-Plan hospital, you should con-                    mined by the Plan. The services will be
   tact Blue Shield at the telephone number on                  reviewed retrospectively by the Plan to
   your identification card.                                    determine whether the services were ur-
                                                                gent services. If the Plan determines that
5. Claims for Emergency and Out-of-Area Ur-                     the services would not have been author-
   gent Services. Contact Member Services to                    ized, and therefore, are not covered, it
   obtain a claim form.                                         will notify the Member of that determi-
                                                                nation. The Plan will notify the Member
   a. Emergency. If emergency services were                     of its determination within 30 days from
      received and expenses were incurred by                    receipt of the claim.
      the Member, for services other than
      medical transportation, the Member                  J. Urgent Services
      must submit a complete claim with the               Urgent services are provided in response to the
      emergency service record for payment to             patient’s need for a prompt diagnostic workup
      the Plan, within 1 year after the first pro-        and/or treatment.
      vision of emergency services for which

                                                     84
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
These services are applicable for a medical or                 for care that involves a surgical or other
mental disorder that: (1) could become an                      procedure or inpatient stay. Blue Shield may
emergency if not diagnosed and/or treated in a                 direct the Member to receive the additional
timely manner, (2) is likely to result in prolonged            follow-up care from the Personal Physician.
temporary impairment, (3) could increase the
risk of necessitating more complex or hazardous            3. When outside the United States, Members
treatment, and (4) could develop in a chronic                 may call the BlueCard Worldwide Network
illness or inordinate physical or psychological               at 1-804-673-1177. Urgent services are avail-
suffering of the patient.                                     able through the BlueCard Worldwide Net-
                                                              work, but may be received from any
1. When within California, but outside of your                provider.
   Personal Physician service area, if possible
   contact Blue Shield Member Services at                      Before traveling abroad, Members should
   1-800-334-5847 for assistance in receiving                  call their local Member Services office for
   urgent services. Member Services will assist                the most current listing of participating pro-
   Members in receiving urgent services                        viders worldwide or they can go on-line at
   through a Blue Shield of California Plan                    http://www.bcbs.com and select the “Find
   provider. Members may also locate a Plan                    a Doctor or Hospital” tab. However, a
   provider by visiting Blue Shield’s internet site            Member is not required to receive urgent
   at http://www.blueshieldca.com. You are                     services outside of the United States from
   not required to use a Blue Shield of Califor-               the BlueCard Worldwide Network. If the
   nia Plan provider to receive urgent services;               Member does not use the BlueCard World-
   you may use any provider. However, the                      wide Network, a claim must be submitted as
   services will be reviewed retrospectively by                described in Section I.5. Claims for Emer-
   the Plan to determine whether the services                  gency and Out-of-Area Urgent Services.
   were urgent services.
                                                           4. To receive urgent care within your service
2. When temporarily traveling within the                      area, call your Personal Physician’s office or
   United States, call the 24-hour toll-free                  follow instructions given by your assigned
   number 1-800-810-BLUE (2583) to obtain                     medical group or IPA in accordance with all
   information about the nearest BlueCard                     the conditions of the Agreement.
   Program participating provider. When a
   BlueCard Program participating provider is                      Copayment: $25 per visit.
   available, you should obtain out-of-area ur-
   gent or follow-up care from a participating             K. Home Health Care Services,
   provider whenever possible, but you may                    PKU-Related Formulas and
   also receive care from a non-participating                 Special Food Products, and
   BlueCard Program provider. If you received                 Home Infusion Therapy
   services from a non-Blue Shield provider,               1. Home Health Care Services
   you must submit a claim to Blue Shield for
   payment. The services will be reviewed ret-                 Benefits are provided for home health care
   rospectively by the Plan to determine                       services when the services are medically
   whether the services were urgent services.                  necessary, ordered by the Personal Physician
   See Section I.5. Claims for Emergency and                   and authorized.
   Out-of-Area Urgent Services for additional
   information.                                                a. Home visits to provide skilled nursing
                                                                  services and other skilled services by any
    Up to two medically necessary out-of-area                     of the following professional providers
    follow-up care outpatient visits are covered.                 are covered:
    Authorization by Blue Shield is required for
    more than two follow-up outpatient visits or                  1) Registered nurse;


                                                      85
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
       2) Licensed vocational nurse;                            ized and must be prescribed or ordered by
                                                                the appropriate health care professional.
       3) Certified home health aide in con-
          junction with the services of 1) or 2),                   Copayment: No charge.
          above;
                                                            3. Home Infusion/Home Injectable Therapy
       4) Medical Social Worker.                               Provided by a Home Infusion Agency
        Copayment: No charge.
                                                                Benefits are provided for home infusion and
                                                                intravenous (IV) injectable therapy when
       5) Physical     therapist,   occupational
                                                                provided by a home infusion agency. Note:
          therapist, or speech therapist.
                                                                For services related to hemophilia, see item
        Copayment: $10 per visit.                               4. below.

    b. In conjunction with the professional ser-                Services include home infusion agency
       vices rendered by a home health agency,                  skilled nursing services, parenteral nutrition
       medical supplies used during a covered                   services and associated supplements, medi-
       visit by the home health agency neces-                   cal supplies used during a covered visit,
       sary for the home health care treatment                  pharmaceuticals administered intravenously,
       plan, and related laboratory services to                 related laboratory services and for medically
       the extent the benefit would have been                   necessary, FDA approved injectable medica-
       provided had the Member remained in                      tions, when prescribed by the Personal Phy-
       the hospital or skilled nursing facility, ex-            sician and prior authorized, and when
       cept as excluded in the General Exclu-                   provided by a home infusion agency.
       sions and Limitations.
                                                                This benefit does not include medications,
        Copayment: No charge.                                   drugs, insulin, insulin syringes, specialty
                                                                drugs covered under Section P., and services
This benefit does not include medications,                      related to hemophilia which are covered as
drugs, or injectables covered under Section K.                  described below.
or P.
                                                                    Copayment: No charge.
See Section O. for information about when a
Member is admitted into a hospice program and               Skilled Nursing Services are defined as a level of
a specialized description of skilled nursing ser-           care that includes services that can only be per-
vices for hospice care.                                     formed safely and correctly by a licensed nurse
                                                            (either a registered nurse or a licensed vocational
For information concerning diabetes self-                   nurse).
management training, see Section V.
                                                            4. Hemophilia Home Infusion Products and
2. PKU-Related Formulas and Special Food                       Services
   Products
                                                                Benefits are provided for home infusion
    Benefits are provided for enteral formulas,                 products for the treatment of hemophilia
    related medical supplies and special food                   and other bleeding disorders. All services
    products that are medically necessary for the               must be prior authorized by the Plan and
    treatment of phenylketonuria (PKU) to                       must be provided by a preferred Hemo-
    avert the development of serious physical or                philia Infusion Provider. (Note: Most par-
    mental disabilities or to promote normal de-                ticipating home health care and home
    velopment or function as a consequence of                   infusion agencies are not preferred Hemo-
    PKU. These benefits must be prior author-                   philia Infusion Providers.) To find a pre-
                                                                ferred Hemophilia Infusion Provider,

                                                       86
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
 consult the Preferred Provider Directory.                  elsewhere in this Benefit Descriptions sec-
 You may also verify this information by call-              tion.
 ing Member Services at the telephone num-
 ber shown on the back cover of this                            Copayment: $10 per visit.
 booklet.
                                                        L. Physical and Occupational Therapy
 Hemophilia Infusion Providers offer 24-                Rehabilitation services include physical therapy,
 hour service and provide prompt home de-               occupational therapy, and/or respiratory ther-
 livery of hemophilia infusion products.                apy. Benefits for speech therapy are described in
                                                        Section M.
 Following evaluation by your physician, a
 prescription for a blood factor product must                   Copayment: $10 per visit for inpatient
 be submitted to and approved by the Plan.                      or outpatient therapy.
 Once prior authorized by the Plan, the
 blood factor product is covered on a regu-             M. Speech Therapy
 larly scheduled basis (routine prophylaxis) or         Outpatient benefits for speech therapy services
 when a non-emergency injury or bleeding                when diagnosed and ordered by a physician and
 episode occurs. (Emergencies will be cov-              provided by an appropriately licensed speech
 ered as described in Section I.)                       therapist, pursuant to a written treatment plan
                                                        for an appropriate time to: (1) correct or im-
 Included in this benefit is the blood factor           prove the speech abnormality, or (2) evaluate
 product for in-home infusion use by the                the effectiveness of treatment, and when ren-
 Member, necessary supplies such as ports               dered in the provider’s office or outpatient de-
 and syringes, and necessary nursing visits.            partment of a hospital.
 Services for the treatment of hemophilia
 outside the home, except for services in in-           Services are provided for the correction of, or
 fusion suites managed by a preferred He-               clinically significant improvement of, speech
 mophilia Infusion Provider, and medically              abnormalities that are the likely result of a diag-
 necessary services to treat complications of           nosed and identifiable medical condition, illness,
 hemophilia replacement therapy are not                 or injury to the nervous system or to the vocal,
 covered under this benefit but may be cov-             swallowing, or auditory organs.
 ered under other medical benefits described
 elsewhere in this Benefit Descriptions sec-            Continued outpatient benefits will be provided
 tion.                                                  for medically necessary services as long as con-
                                                        tinued treatment is medically necessary, pursu-
 This benefit does not include:                         ant to the treatment plan, and likely to result in
                                                        clinically significant progress as measured by ob-
 a. Physical therapy, gene therapy or medi-             jective and standardized tests. The provider’s
    cations including antifibrinolytic and              treatment plan and records will be reviewed pe-
    hormone medications*;                               riodically. When continued treatment is not
                                                        medically necessary pursuant to the treatment
 b. Services from a hemophilia treatment                plan, not likely to result in additional clinically
    center or any provider not prior author-            significant improvement, or no longer requires
    ized by the Plan; or,                               skilled services of a licensed speech therapist,
 c. Self-infusion training programs, other              the Member will be notified of this determina-
    than nursing visits to assist in administra-        tion and benefits will not be provided for ser-
    tion of the product.                                vices rendered after the date of written
                                                        notification.
 *Services and certain drugs may be covered
 under Section L., Section P., or as described          Except as specified above and as stated under
                                                        Section K., no outpatient benefits are provided


                                                   87
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
for speech therapy, speech correction, or speech          Note: Hospice services provided by a non-
pathology services.                                       participating hospice agency are not covered ex-
                                                          cept in certain circumstances in counties in Cali-
        Copayment: $10 per visit for inpatient            fornia in which there are no participating
        or outpatient therapy.                            hospice agencies. If Blue Shield prior authorizes
                                                          hospice program services from a non-contracted
See Section K. for information on coverage for            hospice, the Member’s copayment for these ser-
speech therapy services rendered in the home.             vices will be the same as the copayments for
See Section A. for information on inpatient               hospice program services when received and au-
benefits and Section O. for hospice program               thorized by a participating hospice agency.
services.
                                                          All of the services listed below must be received
N. Skilled Nursing Facility Services                      through the participating hospice agency.
Subject to all of the inpatient hospital services
provisions under Section A., medically necessary          1. Pre-hospice consultative visit regarding pain
skilled nursing services, including subacute care,           and symptom management, hospice and
will be covered when provided in a skilled nurs-             other care options including care planning
ing facility and authorized. This benefit is lim-            (Members do not have to be enrolled in the
ited to 100 days during any calendar year except             hospice program to receive this benefit).
when received through a hospice program pro-
vided by a participating hospice agency. Custo-           2. Interdisciplinary Team care with develop-
dial care is not covered.                                    ment and maintenance of an appropriate
                                                             plan of care and management of terminal
For information concerning “Hospice Program                  illness and related conditions.
Services” see Section O.
                                                          3. Skilled nursing services, certified health aide
        Copayment: No charge.                                services and homemaker services under the
                                                             supervision of a qualified registered nurse.
O. Hospice Program Services
Benefits are provided for the following services          4. Bereavement services.
through a participating hospice agency when an
eligible Member requests admission to and is              5. Social services/counseling services with
formally admitted to an approved hospice pro-                medical social services provided by a quali-
gram. The Member must have a terminal illness                fied social worker. Dietary counseling, by a
as determined by his Plan provider’s certifica-              qualified provider, shall also be provided
tion and the admission must receive prior ap-                when needed.
proval from Blue Shield. (Note: Members with
a terminal illness who have not elected to enroll         6. Medical direction with the medical director
in a hospice program can receive a pre-hospice               being also responsible for meeting the gen-
consultative visit from a participating hospice              eral medical needs for the terminal illness of
agency.) Covered services are available on a 24-             the Members to the extent that these needs
hour basis to the extent necessary to meet the               are not met by the Personal Physician.
needs of individuals for care that is reasonable
and necessary for the palliation and manage-              7. Volunteer services.
ment of terminal illness and related conditions.
Members can continue to receive covered ser-              8. Short-term inpatient care arrangements.
vices that are not related to the palliation and
                                                          9. Pharmaceuticals, medical equipment and
management of the terminal illness from the
                                                             supplies that are reasonable and necessary
appropriate Plan provider. Member copayments
                                                             for the palliation and management of termi-
when applicable are paid to the participating
                                                             nal illness and related conditions.
hospice agency.


                                                     88
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
10. Physical therapy, occupational therapy, and            services or home health aide services may be
    speech-language pathology services for pur-            provided to supplement the nursing care. When
    poses of symptom control, or to enable the             fewer than 8 hours of nursing care are required,
    enrollee to maintain activities of daily living        the services are covered as routine home care
    and basic functional skills.                           rather than continuous home care.

11. Nursing care services are covered on a con-            Home Health Aide Services - services provid-
    tinuous basis for as much as 24 hours a day            ing for the personal care of the terminally ill
    during periods of crisis as necessary to               Member and the performance of related tasks in
    maintain a Member at home. Hospitaliza-                the Member’s home in accordance with the plan
    tion is covered when the Interdisciplinary             of care in order to increase the level of comfort
    Team makes the determination that skilled              and to maintain personal hygiene and a safe,
    nursing care is required at a level that cannot        healthy environment for the patient. Home
    be provided in the home. Either home-                  health aide services shall be provided by a per-
    maker services or home health aide services            son who is certified by the California Depart-
    or both may be covered on a 24-hour con-               ment of Health Services as a home health aide
    tinuous basis during periods of crisis but the         pursuant to Chapter 8 of Division 2 of the
    care provided during these periods must be             Health and Safety Code.
    predominantly nursing care.
                                                           Homemaker Services - services that assist in
12. Respite care services are limited to an occa-          the maintenance of a safe and healthy environ-
    sional basis and to no more than 5 consecu-            ment and services to enable the Member to
    tive days at a time.                                   carry out the treatment plan.

Members are allowed to change their participat-            Hospice Service or Hospice Program - a
ing hospice agency only once during each period            specialized form of interdisciplinary health care
of care. Members can receive care for two 90-              that is designed to provide palliative care, allevi-
day periods followed by an unlimited number of             ate the physical, emotional, social and spiritual
60-day periods. The care continues through an-             discomforts of a Member who is experiencing
other period of care if the Plan provider recerti-         the last phases of life due to the existence of a
fies that the Member is terminally ill.                    terminal disease, to provide supportive care to
                                                           the primary caregiver and the family of the hos-
Definitions                                                pice patient, and which meets all of the follow-
Bereavement Services - services available to               ing criteria:
the immediate surviving family members for a
period of at least 1 year after the death of the           1. Considers the Member and the Member’s
Member. These services shall include an assess-               family in addition to the Member, as the
ment of the needs of the bereaved family and                  unit of care.
the development of a care plan that meets these
needs, both prior to, and following the death of           2. Utilizes an Interdisciplinary Team to assess
the Member.                                                   the physical, medical, psychological, social
                                                              and spiritual needs of the Member and the
Continuous Home Care - home care provided                     Member’s family.
during a period of crisis. A minimum of 8 hours
of continuous care, during a 24-hour day, be-              3. Requires the Interdisciplinary Team to de-
ginning and ending at midnight is required. This              velop an overall plan of care and to provide
care could be 4 hours in the morning and an-                  coordinated care which emphasizes suppor-
other 4 hours in the evening. Nursing care must               tive services, including, but not limited to,
be provided for more than half of the period of               home care, pain control, and short-term in-
care and must be provided by either a registered              patient services. Short-term inpatient ser-
nurse or licensed practical nurse. Homemaker                  vices are intended to ensure both continuity
                                                              of care and appropriateness of services for

                                                      89
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    those Members who cannot be managed at                Period of Crisis - a period in which the Mem-
    home because of acute complications or the            ber requires continuous care to achieve pallia-
    temporary absence of a capable primary                tion or management of acute medical
    caregiver.                                            symptoms.

4. Provides for the palliative medical treatment          Plan of Care - a written plan developed by the
   of pain and other symptoms associated with             attending physician and surgeon, the “medical
   a terminal disease, but does not provide for           director” (as defined under “Medical Direc-
   efforts to cure the disease.                           tion”) or physician and surgeon designee, and
                                                          the Interdisciplinary Team that addresses the
5. Provides for bereavement services following            needs of a Member and family admitted to the
   the Member’s death to assist the family to             hospice program. The hospice shall retain over-
   cope with social and emotional needs asso-             all responsibility for the development and main-
   ciated with the death of the Member.                   tenance of the plan of care and quality of
                                                          services delivered.
6. Actively utilizes volunteers in the delivery of
   hospice services.                                      Respite Care Services - short-term inpatient
                                                          care provided to the Member only when neces-
7. Provides services in the Member’s home or              sary to relieve the family members or other per-
   primary place of residence to the extent ap-           sons caring for the Member.
   propriate based on the medical needs of the
   Member.                                                Skilled Nursing Services - nursing services
                                                          provided by or under the supervision of a regis-
8. Is provided through a participating hospice            tered nurse under a plan of care developed by
   agency.                                                the Interdisciplinary Team and the Member’s
                                                          Plan provider to a Member and his family that
Interdisciplinary Team - the hospice care                 pertain to the palliative, supportive services re-
team that includes, but is not limited to, the            quired by a Member with a terminal illness.
Member and the Member’s family, a physician               Skilled nursing services include, but are not lim-
and surgeon, a registered nurse, a social worker,         ited to, Member assessment, evaluation and case
a volunteer, and a spiritual caregiver.                   management of the medical nursing needs of
                                                          the Member, the performance of prescribed
Medical Direction - services provided by a li-            medical treatment for pain and symptom con-
censed physician and surgeon who is charged               trol, the provision of emotional support to both
with the responsibility of acting as a consultant         the Member and his family, and the instruction
to the Interdisciplinary Team, a consultant to            of caregivers in providing personal care to the
the Member’s Personal Physician, as requested,            enrollee. Skilled nursing services provide for the
with regard to pain and symptom management,               continuity of services for the Member and his
and liaison with physicians and surgeons in the           family and are available on a 24-hour on-call ba-
community. For purposes of this section, the              sis.
person providing these services shall be referred
to as the “medical director”.                             Social Service/Counseling Services - those
                                                          counseling and spiritual services that assist the
Period of Care - the time when the Personal               Member and his family to minimize stresses and
Physician recertifies that the Member still needs         problems that arise from social, economic, psy-
and remains eligible for hospice care even if the         chological, or spiritual needs by utilizing appro-
Member lives longer than 1 year. A period of              priate community resources, and maximize
care starts the day the Member begins to receive          positive aspects and opportunities for growth.
hospice care and ends when the 90 or 60-day
period has ended.                                         Terminal Disease or Terminal Illness - a
                                                          medical condition resulting in a prognosis of life


                                                     90
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
of 1 year or less, if the disease follows its natural              ered for Members. See Section Y. for more in-
course.                                                            formation about smoking cessation.

Volunteer Services - services provided by                          Drugs and supplies covered under Medicare
trained hospice volunteers who have agreed to                      Part B are not covered under this Prescription
provide service under the direction of a hospice                   Drugs benefit. See Section Y. for information
staff member who has been designated by the                        on drugs and supplies covered under Medicare
hospice to provide direction to hospice volun-                     Part B.
teers. Hospice volunteers may provide support
and companionship to the Member and his fam-                       Outpatient Drug Formulary
ily during the remaining days of the Member’s                      Medications are selected for inclusion in Blue
life and to the surviving family following the                     Shield’s Outpatient Drug Formulary based on
Member’s death.                                                    safety, efficacy, FDA bioequivalency data and
                                                                   then cost. New drugs and clinical data are re-
         Copayment: No charge.                                     viewed regularly to update the Formulary. Drugs
                                                                   considered for inclusion or exclusion from the
P. Prescription Drugs                                              Formulary are reviewed by Blue Shield’s Phar-
Except for the calendar year maximum copayments and                macy and Therapeutics Committee during
the Coordination of Benefits provision, the general provi-         scheduled meetings four times a year.
sions and exclusions of the HMO Health Plan Agree-
ment shall apply.                                                  Members may call Blue Shield Member Services
                                                                   at the number listed on their Blue Shield identi-
This plan's prescription drug coverage is on average               fication card to inquire if a specific drug is in-
equivalent to or better than the standard benefit set by           cluded in the Formulary. Member Services can
the federal government for Medicare Part D (also called            also provide Members with a printed copy of
creditable coverage). Because this Plan’s prescription drug        the Formulary. Members may also access the
coverage is creditable, you do not have to enroll in Medi-         Formulary through the Blue Shield of California
care Part D while you maintain this coverage; however,             Web site at http://www.blueshieldca.com.
you should be aware that if you have a subsequent break
in this coverage of 63 days or more before enrolling in            Benefits may be provided for non-Formulary
Medicare Part D you could be subject to payment of                 drugs subject to higher copayments.
higher Part D premiums.
                                                                   Definitions
Benefits are provided for outpatient prescription                  Brand Name Drugs - drugs which are FDA
drugs which meet all of the requirements speci-                    approved either (1) after a new drug application,
fied in this section, are prescribed by a physician                or (2) after an abbreviated new drug application
or other licensed health care provider within the                  and which has the same brand name as that of
scope of his or her license as long as the pre-                    the manufacturer with the original FDA ap-
scriber is a Plan provider, are obtained from a                    proval.
participating pharmacy, and are listed in the
Drug Formulary. Drug coverage is based on the                      Drugs - (1) drugs which are approved by the
use of Blue Shield’s Outpatient Drug Formulary,                    Food and Drug Administration (FDA), requir-
which is updated on an ongoing basis by Blue                       ing a prescription either by federal or California
Shield's Pharmacy and Therapeutics Committee.                      law, (2) insulin, and disposable hypodermic insu-
Non-Formulary drugs may be covered subject                         lin needles and syringes, (3) pen delivery systems
to higher copayments. Select drugs and drug                        for the administration of insulin as determined
dosages and most specialty drugs require prior                     by Blue Shield to be medically necessary, (4) oral
authorization by Blue Shield for medical neces-                    contraceptives and diaphragms, and (5) inhalers
sity, appropriateness of therapy or when effec-                    and inhaler spacers for the management and
tive, lower cost alternatives are available.                       treatment of asthma. Note: No prescription is
Prescription smoking cessation drugs are cov-                      necessary to purchase the items shown in (2)

                                                              91
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
and (3); however, in order to be covered these           tions which usually require close monitoring
items must be ordered by your provider. For the          such as multiple sclerosis, hepatitis, rheumatoid
purposes of this Prescription Drugs benefit,             arthritis, cancer, and other conditions that are
drugs do not include medications and supplies            difficult to treat with traditional therapies. Spe-
covered under Medicare Part B.                           cialty drugs are listed in Blue Shield’s Outpatient
                                                         Drug Formulary. Specialty drugs may be self-
Formulary - a comprehensive list of drugs                administered in the home by injection by the pa-
maintained by Blue Shield's Pharmacy and                 tient or family member (subcutaneously or in-
Therapeutics Committee for use under the Blue            tramuscularly), by inhalation, orally or topically.
Shield Prescription Drug Program, which is de-           Infused or IV medications are not included as
signed to assist physicians in prescribing drugs         specialty drugs. These drugs may also require
that are medically necessary and cost effective.         special handling, may require special manufac-
The Formulary is updated periodically. If not            turing processes, and may have limited prescrib-
otherwise excluded, the Formulary includes all           ing or limited pharmacy availability. Specialty
generic drugs.                                           drugs must be considered safe for self-
                                                         administration by Blue Shield’s Pharmacy and
Generic Drugs - drugs that (1) are approved by           Therapeutics Committee, must be obtained
the FDA as a therapeutic equivalent to the               from a Blue Shield specialty pharmacy and may
brand name drug, (2) contain the same active             require prior authorization for medical necessity
ingredient as the brand name drug, and (3) cost          by Blue Shield.
less than the brand name drug equivalent.
                                                         Specialty Pharmacy Network - select partici-
Maintenance Drugs - covered outpatient pre-              pating pharmacies contracted by Blue Shield to
scription drugs prescribed to treat chronic or           provide covered specialty drugs. These pharma-
long-term conditions including conditions such           cies offer 24-hour clinical services and provide
as diabetes, asthma, hypertension and chronic            prompt home delivery of specialty drugs.
heart disease.
                                                         To select a specialty pharmacy, the Member may
Non-Formulary Drugs - drugs determined by                go to http://www.blueshieldca.com or call
Blue Shield's Pharmacy and Therapeutics Com-             Member Services at 1-800-334-5847.
mittee as being duplicative or as having pre-
ferred Formulary drug alternatives available.            Obtaining Outpatient Prescription
Benefits may be provided for non-Formulary               Drugs at a Participating Pharmacy
drugs and are always subject to the non-                 To obtain drugs at a participating pharmacy, the
Formulary copayment.                                     Member must present his Blue Shield identifica-
                                                         tion card. Note: Except for covered emergen-
Non-Participating Pharmacy - a pharmacy                  cies, claims for drugs obtained without using the
which does not participate in the Blue Shield            identification card will be denied.
Pharmacy Network.
                                                         Benefits are provided for specialty drugs only
Participating Pharmacy - a pharmacy which                when obtained from a Blue Shield specialty
participates in the Blue Shield Pharmacy Net-            pharmacy, except in the case of an emergency.
work. These participating pharmacies have                In the event of an emergency, covered specialty
agreed to a contracted rate for covered prescrip-        drugs that are needed immediately may be ob-
tions for Blue Shield Members.                           tained from any participating pharmacy, or, if
                                                         necessary from a non-participating pharmacy.
To select a participating pharmacy, the Member
may go to http://www.blueshieldca.com or call                    Copayment: $30 per prescription for a
Member Services at 1-800-334-5847.                               30-day supply.
Specialty Drugs - specialty drugs are specific
drugs used to treat complex or chronic condi-

                                                    92
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
The Member is responsible for paying the appli-           paying the applicable brand name drug copay-
cable copayment for each covered new and refill           ment.
prescription drug. The pharmacist will collect
from the Member the applicable copayment at               You may request a reduced copayment for the
the time the drugs are obtained.                          non-Formulary brand name medication through
                                                          Blue Shield’s prior authorization process by ob-
        Copayment: $5 generic, $15 brand                  taining a statement from your provider that
        name*, $45 non-Formulary, 50% of the              clearly attests to the necessity for the non-
        Blue Shield contracted rate for drugs             Formulary product versus the preferred Formu-
        for erectile dysfunction per prescrip-            lary product or available generic alternative. See
        tion for the amount prescribed not to             the section below on Prior Authorization Proc-
        exceed a 30-day supply; after 3                   ess for Select Formulary, Non-Formulary, and
        months, the copayment for Mainte-                 Specialty Drugs for information on the approval
        nance drugs is $10 generic, $25 brand             process. If the request is approved, the reduced
        name, $75 non-Formulary per pre-                  non-Formulary brand name medication copay-
        scription for each subsequent 30-day
                                                          ment will be $40 per 30-day prescription at a re-
        supply.
                                                          tail pharmacy, and you will be charged the
*For diaphragms, the Formulary brand name                 reduced non-Formulary brand name medication
copayment applies.                                        copayment for that specific non-preferred prod-
                                                          uct for 1 year from the date of approval. If you
If the participating pharmacy contracted rate             wish to continue to receive the reduced copay-
charged by the participating pharmacy is less             ment at the end of the 1-year approval period,
than or equal to the Member copayment, the                you will need to make a new request using the
Member will only be required to pay the partici-          process noted above. To avoid paying an in-
pating pharmacy contracted rate.                          creased copayment, it is suggested that you
                                                          submit your new request 30 days prior to the
Prescription drugs administered in a physician’s          expiration of the previous approval. Failure to
office, are covered by the $10 copayment for the          attest to a supportable medical need for a non-
office visit and do not require another copay-            Formulary brand name medication will result in
ment.                                                     denial of the reduced copayment request and
                                                          your non-Formulary copayment will apply. This
Some prescriptions are limited to a maximum al-           does not apply to drugs for erectile dysfunction.
lowable quantity based on medical necessity and
appropriateness of therapy as determined by               When Maintenance drugs have been prescribed
Blue Shield’s Pharmacy and Therapeutics                   for a chronic condition and the Member’s medi-
Committee.                                                cation dosage has been stabilized and he has re-
                                                          ceived the same medication and dosage through
If the Member requests a brand name drug                  the Blue Shield Pharmacy Network for 3
when a generic drug equivalent is available, the          months, he may obtain the drug through the
Member is responsible for paying the difference           Mail Service Prescription Drug Program. If the
between the participating pharmacy contracted             Member continues to obtain the drug from a
rate for the brand name drug and its generic              participating pharmacy, the higher Maintenance
drug equivalent, as well as the applicable generic        drug copayment will apply for each subsequent
drug copayment.                                           30-day supply. Note: This does not apply to
                                                          specialty drugs, nor to any other drugs which are
If the prescription specifies a brand name drug           not available through or cannot safely be ob-
and the prescribing provider has written “Dis-            tained through the Mail Service Prescription
pense As Written” or “Do Not Substitute” on               Drug Program. This also does not apply to
the prescription, or if a generic drug equivalent         Maintenance drugs for which a lower copay-
is not available, the Member is responsible for           ment was approved pursuant to the paragraph
                                                          above.

                                                     93
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Drugs obtained at a non-participating pharmacy                   provider indicates a prescription quan-
are not covered, unless medically necessary for a                tity of less than a 90-day supply, that
covered emergency, including drugs for emer-                     amount will be dispensed and refill au-
gency contraception. If the Member must obtain                   thorizations cannot be combined to
drugs from a non-participating pharmacy due to                   reach a 90-day supply.
an emergency, the submission of a Prescription
Drug Claim is required. Claim forms are avail-           If the participating pharmacy contracted rate is
able by contacting Member Services. Submit               less than or equal to the Member copayment,
completed Prescription Drug Claim form noting            the Member will only be required to pay the par-
"Emergency Request" on form to Blue Shield               ticipating pharmacy contracted rate.
Pharmacy Services, P.O. Box 7168, San Fran-
cisco, CA 94120. Claims must be received                 If the Member requests a mail service brand
within 1 year from the date of service to be con-        name drug when a mail service generic drug
sidered for payment. Reimbursement for cov-              equivalent is available, the Member is responsi-
ered emergency claims will be based upon the             ble for the difference between the contracted
purchase price of covered prescription drug(s)           rate for the mail service brand name drug and its
less any applicable copayment(s).                        mail service generic drug equivalent, as well as
                                                         the applicable mail service generic drug copay-
Obtaining Outpatient Prescription                        ment.
Drugs Through the Mail Service                           If the prescription specifies a mail service brand
Prescription Drug Program                                name drug and the prescribing provider has
For the Member’s convenience, when drugs                 written “Dispense As Written” or “Do Not
have been prescribed for a chronic condition             Substitute” on the prescription, or if a mail ser-
and the Member's medication dosage has been              vice generic drug equivalent is not available, the
stabilized, he may obtain the drug through Blue          Member is responsible for paying the applicable
Shield's Mail Service Prescription Drug Pro-             mail service brand name drug copayment.
gram. The Member may continue to obtain the
drug from a participating pharmacy; however,             You may request a reduced copayment for the
after 3 months, the higher Maintenance drug              non-Formulary brand name medication through
copayment will apply for each subsequent 30-             Blue Shield’s prior authorization process by ob-
day supply. Blue Shield will provide mail order          taining a statement from your provider that
forms and information at the time of enroll-             clearly attests to the necessity for the non-
ment. The Member’s provider must indicate a              Formulary product versus the preferred Formu-
prescription quantity which is equal to the              lary product or available generic alternative. See
amount to be dispensed. Note: This does not              the section below on Prior Authorization Proc-
apply to specialty drugs, nor to any other drugs         ess for Select Formulary, Non-Formulary, and
which are not available through or cannot safely         Specialty Drugs for information on the approval
be obtained through the Mail Service Prescrip-           process. If the request is approved, the reduced
tion Drug Program.                                       non-Formulary brand name medication copay-
                                                         ment will be $70 for up to a 90-day supply pre-
The Member is responsible for paying the appli-          scription at the mail service pharmacy, and you
cable copayment for each covered new and refill          will be charged the reduced non-Formulary
prescription drug. Copayments will be tracked            brand name medication copayment for that spe-
for the Member.                                          cific non-preferred product for 1 year from the
                                                         date of approval. If you wish to continue to re-
        Copayment: $10 generic, $25 brand                ceive the reduced copayment at the end of the
        name, $75 non-Formulary per pre-
                                                         1-year approval period, you will need to make a
        scription not to exceed a 90-day sup-
                                                         new request using the process noted above. To
        ply; $1,000 out-of-pocket annual
        maximum, then no charge excluding                avoid paying an increased copayment, it is sug-
        non-Formulary drugs. If the Member’s             gested that you submit your new request 30 days
                                                         prior to the expiration of the previous approval.

                                                    94
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Failure to attest to a supportable medical need               vider's office (see A. Hospital Services and
for a non-Formulary brand name medication                     B. Physician Services);
will result in denial of the reduced copayment
request and your non-Formulary copayment will             3. Take home drugs received from a hospital,
apply. This does not apply to drugs for erectile             convalescent home, skilled nursing facility,
dysfunction.                                                 or similar facility (see A. Hospital Services
                                                             and N. Skilled Nursing Facility Services);
For information about the Mail Service Pre-
scription Drug Program, the Member may refer              4. Drugs except as specifically listed as covered
to the mail service program brochure for the                 under this Section P., drugs which can be
phone number and a more detailed explanation                 obtained without a prescription or for which
or call Blue Shield Member Services at 1-800-                there is a non-prescription drug that is the
334-5847. The TTY telephone number is 1-866-                 identical chemical equivalent (i.e., same ac-
346-7197.                                                    tive ingredient and dosage) to a prescription
                                                             drug;
Prior Authorization Process for
Select Formulary, Non-Formulary, and                      5. Drugs for which the Member is not legally
Specialty Drugs                                              obligated to pay, or for which no charge is
Select Formulary drugs, as well as most specialty            made;
drugs may require prior authorization for medi-
                                                          6. Drugs that are considered to be experimen-
cal necessity. Select non-Formulary drugs may
                                                             tal or investigational;
require prior authorization for medical necessity,
and to determine if lower cost alternatives are
                                                          7. Medical devices or supplies, except as spe-
available and just as effective. Your physician
                                                             cifically listed as covered herein (see E. Du-
may request prior authorization by submitting
                                                             rable Medical Equipment, Prostheses and
supporting information to Blue Shield. Once all
                                                             Orthoses and Other Services). This exclu-
required supporting information is received,
                                                             sion also includes topically applied prescrip-
prior authorization approval or denial, based
                                                             tion preparations that are approved by the
upon medical necessity, is provided within 5
                                                             FDA as medical devices;
business days or within 72 hours for an expe-
dited review.                                             8. Drugs when prescribed for cosmetic pur-
                                                             poses, including but not limited to drugs
Exclusions                                                   used to retard or reverse the effects of skin
No benefits are provided under the Prescription              aging or to treat hair loss;
Drugs benefit for the following (please note,
certain services excluded below may be covered            9. Dietary or nutritional products (see K.
under other benefits/portions of this Evidence               Home Health Care Services, PKU-Related
of Coverage – you should refer to the applicable             Formulas and Special Food Products, and
section to determine if drugs are covered under              Home Infusion Therapy);
that benefit):
                                                          10. Injectable drugs which are not self- adminis-
1. Drugs obtained from a non-participating                    tered. Other injectable medications may be
   pharmacy, except for a covered emergency,                  covered under Z. Additional Services;
   drugs for emergency contraception, and
   drugs obtained outside of California which             11. Appetite suppressants or drugs for body
   are related to an urgently needed service and              weight reduction except when medically
   for which a participating pharmacy was not                 necessary for the treatment of morbid obe-
   reasonably accessible;                                     sity. In such cases the drug will be subject to
                                                              prior authorization from Blue Shield;
2. Any drug provided or administered while
   the Member is an inpatient, or in a pro-

                                                     95
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
12. Drugs when prescribed for smoking cessa-              For prior authorization for mental health and
    tion purposes, except as provided under this          substance abuse services, Members should con-
    Section P.;                                           tact the MHSA at 1-866-505-3409.

13. Compounded medications if: (1) there is a             All non-emergency mental health and substance
    medically appropriate Formulary alternative,          abuse services must be obtained from MHSA
    or, (2) there are no FDA-approved indica-             Participating Providers. (See the How to Use the
    tions. Compounded medications that do not             Plan section, the Mental Health and Substance
    include at least one drug, as defined, are not        Abuse Services paragraphs for more informa-
    covered;                                              tion.)

14. Replacement of lost, stolen or destroyed              Benefits are provided for the following medi-
    prescription drugs;                                   cally necessary covered mental health conditions
                                                          and substance abuse conditions, subject to ap-
15. Drugs prescribed for treatment of dental              plicable copayments and charges in excess of
    conditions. This exclusion shall not apply to         any benefit maximums. Coverage for these ser-
    antibiotics prescribed to treat infection nor         vices is subject to all terms, conditions, limita-
    to medications prescribed to treat pain;              tions and exclusions of the Agreement, to any
                                                          conditions or limitations set forth in the benefit
16. Drugs or supplies covered under Medicare              description below, and to the Exclusions and
    Part B (see Y. Medicare Part B Covered                Limitations set forth in this booklet.
    Drugs and Supplies);
                                                          Benefits are provided for inpatient hospital and
17. Drugs packaged in convenience kits that in-           professional services in connection with hospi-
    clude non-prescription convenience items,             talization for the treatment of mental health
    unless the drug is not otherwise available            conditions and substance abuse conditions. All
    without the non-prescription components.              non-emergency mental health and substance
    This exclusion shall not apply to items used          abuse services must be prior authorized by the
    for the administration of diabetes or asthma          MHSA and obtained from MHSA Participating
    drugs.                                                Providers. Residential care is not covered.

Call Member Services at 1-800-334-5847 for fur-           See Section A. for information on medically
ther information.                                         necessary inpatient substance abuse detoxifica-
                                                          tion.
See the Grievance Process section of this Evi-
dence of Coverage for information on filing a                     Copayment: No charge.
grievance, your right to seek assistance from the
Department of Managed Health Care and your                R. Outpatient Mental Health and
rights to independent medical review.                        Substance Abuse Services
                                                          1. Benefits are provided for outpatient facility
Q. Inpatient Mental Health and                               and office visits for mental health condi-
   Substance Abuse Services                                  tions and substance abuse conditions.
Blue Shield of California’s MHSA administers
and delivers the Plan’s mental health and sub-                    Copayment: $10 per visit.
stance abuse benefits. These services are pro-
vided through a unique network of MHSA                    2. Benefits are provided for hospital and pro-
Participating Providers. All non-emergency                   fessional services in connection with partial
mental health and substance abuse services must              hospitalization for the treatment of mental
be arranged through the MHSA. Also, all non-                 health conditions and substance abuse con-
emergency mental health and substance abuse                  ditions.
services must be prior authorized by the MHSA.
                                                                  Copayment: No charge.

                                                     96
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
3. Psychosocial Support through LifeReferrals               7. Dental and orthodontic services that are an
   24/7                                                        integral part of reconstructive surgery for
                                                               cleft palate repair.
    See the Mental Health and Substance Abuse
    Services paragraphs under the How to Use                        Copayment: See applicable copay-
    the Plan section for information on psycho-                     ments for Physician Services and Hos-
    social support services.                                        pital Services.

        Copayment: No charge.                               This benefit does not include:

S. Medical Treatment of the Teeth,                          1. Services performed on the teeth, gums
   Gums, Jaw Joints or Jaw Bones                               (other than for tumors and dental and or-
Hospital and professional services provided for                thodontic services that are an integral part
conditions of the teeth, gums or jaw joints and                of reconstructive surgery for cleft palate re-
jaw bones, including adjacent tissues are a bene-              pair) and associated periodontal structures,
fit only to the extent that they are provided for:             routine care of teeth and gums, diagnostic
                                                               services, preventive or periodontic services,
1. The treatment of tumors of the gums;                        dental orthosis and prosthesis, including
                                                               hospitalization incident thereto;
2. The treatment of damage to natural teeth
   caused solely by an accidental injury is lim-            2. Orthodontia (dental services to correct ir-
   ited to medically necessary services until the              regularities or malocclusion of the teeth) for
   services result in initial, palliative stabiliza-           any reason (except for orthodontic services
   tion of the Member as determined by the                     that are an integral part of reconstructive
   Plan;                                                       surgery for cleft palate repair), including
                                                               treatment to alleviate TMJ;
    Dental services provided after initial medical
    stabilization, prosthodontics, orthodontia              3. Any procedure (e.g., vestibuloplasty) in-
    and cosmetic services are not covered. This                tended to prepare the mouth for dentures or
    benefit does not include damage to the                     for the more comfortable use of dentures;
    natural teeth that is not accidental (e.g., re-
    sulting from chewing or biting).                        4. Dental implants (endosteal, subperiosteal or
                                                               transosteal);
3. Medically necessary non-surgical treatment
   (e.g., splint and physical therapy) of Tem-              5. Alveolar ridge surgery of the jaws if per-
   poromandibular Joint Syndrome (TMJ);                        formed primarily to treat diseases related to
                                                               the teeth, gums or periodontal structures or
4. Surgical and arthroscopic treatment of TMJ                  to support natural or prosthetic teeth;
   if prior history shows conservative medical
   treatment has failed;                                    6. Fluoride treatments except when used with
                                                               radiation therapy to the oral cavity.
5. Medically necessary treatment of maxilla and
   mandible (jaw joints and jaw bones);                     See the Exclusions and Limitations section for
                                                            additional services that are not covered.
6. Orthognathic surgery (surgery to reposition
   the upper and/or lower jaw) which is medi-               T. Special Transplant Benefits
   cally necessary to correct skeletal deformity;           Benefits are provided for certain procedures
   or                                                       listed below only if: (1) performed at a Trans-
                                                            plant Network Facility approved by Blue Shield
                                                            of California to provide the procedure, (2) prior
                                                            authorization is obtained, in writing, from the


                                                       97
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Blue Shield Corporate Medical Director, and                   apy when such treatment is medically
(3) the recipient of the transplant is a Member.              necessary and is not experimental or investi-
                                                              gational;
The Blue Shield Corporate Medical Director
shall review all requests for prior authorization         7. Pediatric human small bowel transplants;
and shall approve or deny benefits, based on the
medical circumstances of the patient, and in ac-          8. Pediatric and adult human small bowel and
cordance with established Blue Shield medical                liver transplants in combination.
policy. Failure to obtain prior written authoriza-
tion as described above and/or failure to have            Reasonable charges for services incident to ob-
the procedure performed at a Blue Shield ap-              taining the transplanted material from a living
proved Transplant Network Facility will result            donor or an organ transplant bank will be cov-
in denial of claims for this benefit.                     ered.

Pre-transplant evaluation and diagnostic tests,                   Copayment: Physician Services and
transplantation and follow-ups will be allowed                    Hospital Services copayments apply.
only at a Blue Shield approved Transplant Net-
work       Facility. Non-acute/non-emergency              U. Organ Transplant Benefits
evaluations, transplantations and follow-ups at           Hospital and professional services provided in
facilities other than a Blue Shield Transplant            connection with human organ transplants are a
Network Facility will not be approved. Evalua-            benefit to the extent that they are provided in
tion of potential candidates at a Blue Shield             connection with the transplant of a cornea, kid-
Transplant Network Facility is covered subject            ney, or skin, and the recipient of such transplant
to prior authorization. In general, more than             is a Member.
one evaluation (including tests) within a short
time period and/or more than one Transplant               Services incident to obtaining the human organ
Network Facility will not be authorized unless            transplant material from a living donor or an or-
the medical necessity of repeating the service is         gan transplant bank will be covered.
documented and approved. For information on
Blue Shield of California’s approved Transplant                   Copayment: Physician Services and
Network, call 1-800-334-5847.                                     Hospital Services copayments apply.

The following procedures are eligible for cover-          V. Diabetes Care
age under this provision:                                 1. Diabetic Equipment

1. Human heart transplants;                                   Benefits are provided for the following de-
                                                              vices and equipment, including replacement
2. Human lung transplants;                                    after the expected life of the item and when
                                                              medically necessary, for the management
3. Human heart and lung transplants in com-                   and treatment of diabetes when medically
   bination;                                                  necessary and authorized:

4. Human liver transplants;                                   a. blood glucose monitors, including those
                                                                 designed to assist the visually impaired;
5. Human kidney and pancreas transplants in
   combination (kidney only transplants are                   b. insulin pumps and all related necessary
   covered under Section U.);                                    supplies;

6. Human bone marrow transplants, including                   c. podiatric devices to prevent or treat dia-
   autologous bone marrow transplantation or                     betes-related complications, including ex-
   autologous peripheral stem cell transplanta-                  tra-depth orthopedic shoes;
   tion used to support high-dose chemother-

                                                     98
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
   d. visual aids, excluding eyewear and/or              in conjunction with plastic and reconstructive
      video-assisted devices, designed to assist         surgeons.
      the visually impaired with proper dosing
      of insulin;                                        No benefits will be provided for the following
                                                         surgeries or procedures unless for reconstructive
   e. for coverage of diabetic testing supplies          surgery:
      including blood and urine testing strips
      and test tablets, lancets and lancet punc-         1. Surgery to excise, enlarge, reduce, or change
      ture devices and pen delivery systems for             the appearance of any part of the body;
      the administration of insulin, see Section
      P.                                                 2. Surgery to reform or reshape skin or bone;
       Copayment: No charge.                             3. Surgery to excise or reduce skin or connec-
                                                            tive tissue that is loose, wrinkled, sagging, or
2. Diabetes Self-Management Training                        excessive on any part of the body;
   Diabetes outpatient self-management train-            4. Hair transplantation; and
   ing, education and medical nutrition therapy
   that is medically necessary to enable a               5. Upper eyelid blepharoplasty without docu-
   Member to properly use the diabetes-related              mented significant visual impairment or
   devices and equipment and any additional                 symptomatology.
   treatment for these services if directed or
   prescribed by the Member’s Personal Physi-            This limitation shall not apply to breast recon-
   cian and authorized. These benefits shall in-         struction when performed subsequent to a mas-
   clude, but not be limited to, instruction that        tectomy, including surgery on either breast to
   will enable diabetic patients and their fami-         achieve or restore symmetry.
   lies to gain an understanding of the diabetic
   disease process, and the daily management                     Copayment: Physician Services and
   of diabetic therapy, in order to thereby                      Hospital Services copayments apply.
   avoid frequent hospitalizations and compli-
   cations.                                              X. Clinical Trials for Cancer
                                                         Benefits are provided for routine patient care
       Copayment: $10 per visit.                         for a Member whose Personal Physician has ob-
                                                         tained prior authorization and who has been ac-
W. Reconstructive Surgery                                cepted into an approved clinical trial for cancer
Medically necessary services in connection with          provided that:
reconstructive surgery when there is no other
more appropriate covered surgical procedure,             1. The clinical trial has a therapeutic intent and
and with regards to appearance, when recon-                 the Member’s treating physician determines
structive surgery offers more than a minimal                that participation in the clinical trial has a
improvement in appearance (including congeni-               meaningful potential to benefit the Member;
tal anomalies) are covered. In accordance with              with a therapeutic intent; and
the Women’s Health & Cancer Rights Act, sur-
gically implanted and other prosthetic devices           2. The Member’s treating physician recom-
(including prosthetic bras) and reconstructive              mends participation in the clinical trial; and
surgery on either breast to restore and achieve
symmetry incident to a mastectomy, and treat-            3. The hospital and/or physician conducting
ment of physical complications of a mastec-                 the clinical trial is a Plan provider, unless the
tomy, including lymphedemas, are covered.                   protocol for the trial is not available through
Surgery must be authorized as described herein.             a Plan provider.
Benefits will be provided in accordance with
guidelines established by the Plan and developed

                                                    99
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Services for routine patient care will be paid on             Y. Medicare Part B Covered Drugs and
the same basis and at the same benefit levels as                 Supplies
other covered services.                                       Certain medications and supplies (such as diabetic
                                                              testing supplies) are covered by Medicare under
Routine patient care consists of those services               Part B. Members will receive primary coverage
that would otherwise be covered by the Plan if                for certain drugs and supplies from Medicare Part
those services were not provided in connection                B, and the Blue Shield Access+ HMO benefit will
with an approved clinical trial, but does not in-             be reduced by the benefits covered by Medicare
clude:                                                        Part B. For additional information regarding
                                                              which medications and supplies are covered un-
1. Drugs or devices that have not been ap-                    der Medicare Part B, you may check online at
   proved by the federal Food and Drug Ad-                    http://www.blueshieldca.com or call Blue Shield
   ministration (FDA);                                        Member Services at 1-800-334-5847.
2. Services other than health care services,                  These medications and supplies can be obtained
   such as travel, housing, companion expenses                through either a mail-order or retail Participat-
   and other non-clinical expenses;                           ing Pharmacy that also participates in Medicare.
                                                              The Participating Pharmacy will verify coverage,
3. Any item or service that is provided solely
                                                              file your prescription claim with Medicare Part
   to satisfy data collection and analysis needs
                                                              B, and submit your claim to the Blue Shield Ac-
   and that is not used in the clinical manage-
                                                              cess+ HMO Supplement to Original Medicare
   ment of the patient;
                                                              Plan for processing.
4. Services that, except for the fact that they
                                                              Most pharmacies can bill Medicare directly for
   are being provided in a clinical trial, are spe-
                                                              these services as the primary payor. If you have
   cifically excluded under the Plan;
                                                              authorized Medicare and Blue Shield to auto-
                                                              matically “crossover” any Part B deductible or
5. Services customarily provided by the re-
                                                              coinsurance amounts remaining after Medicare
   search sponsor free of charge for any enrol-
                                                              Part B has paid, the balance on your claim will
   lee in the trial.
                                                              be automatically sent to your Blue Shield cover-
An approved clinical trial is limited to a trial that         age for processing. The Medicare Explanation
is:                                                           of Benefits (EOMB) will include a statement
                                                              that your secondary claim has been automati-
1. Approved by one of the following:                          cally sent to Blue Shield for processing.

    a. one of the National Institutes of Health;              If you have not authorized Medicare to auto-
                                                              matically crossover the balance, the Participating
    b. the federal Food and Drug Administra-                  Pharmacy will need to submit a claim for this
       tion, in the form of an investigational                amount to Blue Shield. Most pharmacies have
       new drug application;                                  the capability to bill Blue Shield for these sec-
                                                              ondary payments. If your pharmacy is not able
    c. the United States Department of De-                    to send a claim for the secondary payment to
       fense;                                                 Blue Shield, you should file a claim directly with
                                                              Blue Shield by completing the Blue Shield
    d. the United States Veterans’ Administra-                Member Claim Form and attaching a copy of
       tion; or                                               the Medicare Part B EOMB.
2. Involves a drug that is exempt under federal
                                                              If Medicare provides primary coverage for these
   regulations from a new drug application.
                                                              services under Part B, you will not have to pay
        Copayment: Physician Services and                     any copayment. Medicare will pay 80% of the al-
        Hospital Services copayments apply.                   lowable amount. The remaining Medicare Part B

                                                        100
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
deductible (if any) and coinsurance amounts will            P. for information on insulin and specialty
then be paid by Blue Shield.                                drugs coverage and copayment.

If Medicare Part B denies coverage for your                     Copayment: No charge.
claim as primary payor for these services, the
pharmacy must contact Blue Shield for authori-           3. Away From Home Care® Program
zation to submit the entire claim for reim-
bursement directly to Blue Shield for coverage              The Blue Shield Access+ HMO offers to
in your Prescription Drugs benefit, and the                 CalPERS members who are long-term trav-
Member is responsible for any applicable co-                elers, students and families living apart,
payments.                                                   Away From Home Care (AFHC).

Mail-order pharmacy: For Members’ conven-                   AFHC offers full HMO benefits with a local
ience, drugs may be obtained through Blue                   ID card. Membership eligibility is applicable
Shield’s Mail Service Prescription Drug Program             to spouses, domestic partners and depend-
for home delivery. For information regarding                ents who are away from home for at least 90
the Mail Service Prescription Drug Program, the             days, or to members who are away from
Member may refer to the mail service program                home for at least 90 days but not more than
brochure. For additional information, Members               180 days. There is no additional charge to
may contact Blue Shield Member Services at                  the member. AFHC is coordinated by call-
1-800-334-5847.                                             ing 1-800-334-5847.

Retail pharmacy: Present your Medicare ID                   AFHC also offers a special short-term ser-
card with your prescriptions. Most Participating            vice which is available to members requiring
Pharmacies also participate in Medicare Part B.             specific follow-up treatment. This option is
Call Blue Shield Member Services at 1-800-334-              particularly beneficial for members who will
5847 to locate a Participating Pharmacy near                be out-of-state on a short-term basis but re-
you. You may also call Medicare Customer Ser-               quire special treatment.
vice at 1-800-633-4227 to locate a Participating
Pharmacy near you that is a Medicare Part B              4. Hearing Aid Services
participating provider.
                                                            a. Audiological Evaluation. To measure the
Z. Additional Services                                         extent of hearing loss and a hearing aid
1. Personal Health Management Program                          evaluation to determine the most appro-
                                                               priate make and model of hearing aid.
   Health education and health promotion ser-                   Copayment: No charge. Evaluation is
   vices provided by Blue Shield’s Center for                   in addition to the $1,000 maximum al-
   Health Improvement offer a variety of well-                  lowed every 36 months for both ears
   ness resources including, but not limited to:                for the hearing aid and ancillary
   a member newsletter and a prenatal health                    equipment.
   education program.
                                                            b. Hearing Aid. Monaural or binaural in-
       Copayment: No charge.                                   cluding ear mold(s), the hearing aid in-
                                                               strument, the initial battery, cords and
2. Injectable Medications                                      other ancillary equipment. Includes visits
                                                               for fitting, counseling, adjustments, re-
   Injectable medications approved by the                      pairs, etc. at no charge for a 1-year pe-
   FDA are covered for the medically neces-                    riod following the provision of a covered
   sary treatment of medical conditions when                   hearing aid.
   prescribed or authorized by the Personal
   Physician or as described herein. See Section


                                                   101
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
      Excludes the purchase of batteries or                7. Smoking Cessation
      other ancillary equipment, except those
      covered under the terms of the initial                   Members who participate and complete a
      hearing aid purchase and charges for a                   smoking cessation class or program will be
      hearing aid which exceed specifications                  reimbursed up to $100 per class or program
      prescribed for correction of a hearing                   per calendar year. Members may contact
      loss. Excludes replacement parts for                     their medical group or IPA for information
      hearing aids, repair of hearing aid after                about these classes and programs. If you
      the covered 1-year warranty period and                   have a question about the smoking cessation
      replacement of a hearing aid more than                   benefit, you should call Blue Shield Member
      once in any period of 36 months. Also                    Services at 1-800-334-5847.
      excludes surgically implanted hearing de-
      vices.                                               Exclusions and Limitations
                                                           General Exclusions and Limitations
       Limitations: Up to maximum of $1,000
                                                           Unless exceptions to the following exclusions
       per Member every 36 months for both
                                                           are specifically made elsewhere in the Agree-
       ears for the hearing aid instrument,
       and ancillary equipment.                            ment, no benefits are provided for services
                                                           which are:
   To receive these services, you may either
   contact your Personal Physician to obtain a             1. Acupuncture. For or incident to acupunc-
   referral or self-refer to an Access+ Specialist            ture;
   as described in the How to Use the Plan
                                                           2. Behavioral Problems. For learning dis-
   section.
                                                              abilities, behavioral problems or social skills
5. Biofeedback                                                training/therapy;

   Biofeedback therapy is covered only when it             3. Cosmetic Surgery. For cosmetic surgery,
   is reasonable and necessary for the individ-               or any resulting complications, except medi-
   ual patient for muscle re-education of spe-                cally necessary services to treat complica-
   cific muscle groups or for treating                        tions of cosmetic surgery (e.g., infections or
   pathological muscle abnormalities of spas-                 hemorrhages) will be a benefit, but only
   ticity, incapacitating muscle spasm, or weak-              upon review and approval by a Blue Shield
   ness, and more conventional treatments                     physician consultant. Without limiting the
   (heat, cold, massage, exercise, support) have              foregoing, no benefits will be provided for
   not been successful. This therapy is not                   the following surgeries or procedures:
   covered for treatment of ordinary muscle
                                                               • Lower eyelid blepharoplasty;
   tension states or for psychosomatic condi-
   tions.                                                      • Spider veins;
                                                               • Services and procedures to smooth the
       Copayment: No charge.                                     skin (e.g., chemical face peels, laser re-
                                                                 surfacing, and abrasive procedures);
6. Chiropractic Care                                           • Hair removal by electrolysis or other
                                                                 means; and
   Manipulation of the spine to correct a sub-                 • Reimplantation of breast implants
   luxation, upon referral from your Personal                    originally provided for cosmetic aug-
   Physician, when provided by chiropractors                     mentation;
   or other qualified providers.
                                                           4. Custodial or Domiciliary Care. For or in-
       Copayment: $10 per visit.                              cident to services rendered in the home or
                                                              hospitalization or confinement in a health
                                                              facility primarily for custodial, maintenance,

                                                     102
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    domiciliary care or residential care, except as             through a participating hospice agency);
    provided under O.; or rest;                                 treatment (other than surgery) of chronic
                                                                conditions of the foot, including but not
5. Dental Care, Dental Appliances. For den-                     limited to weak or fallen arches, flat or pro-
   tal care or services incident to the treatment,              nated foot, pain or cramp of the foot, bun-
   prevention or relief of pain or dysfunction                  ions, muscle trauma due to exertion or any
   of the temporomandibular joint and/or                        type of massage procedure on the foot; spe-
   muscles of mastication, except as specifically               cial footwear (e.g., non-custom made or
   provided under S.; for or incident to ser-                   over-the-counter shoe inserts or arch sup-
   vices and supplies for treatment of the teeth                ports), except as specifically provided under
   and gums (except for tumors and dental and                   E. and V.;
   orthodontic services that are an integral part
   of reconstructive surgery for cleft palate               9. Genetic Testing. For genetic testing except
   procedures) and associated periodontal                      as described under D. and F.;
   structures, including but not limited to diag-
   nostic, preventive, orthodontic, and other               10. Home Monitoring Equipment. For home
   services such as dental cleaning, tooth whit-                testing devices and monitoring equipment,
   ening, x-rays, topical fluoride treatment ex-                except as specifically provided under E.;
   cept when used with radiation therapy to the
   oral cavity, fillings and root canal treatment;          11. Infertility Reversal. For or incident to the
   treatment of periodontal disease or perio-                   treatment of infertility or any form of as-
   dontal surgery for inflammatory conditions;                  sisted reproductive technology, including
   tooth extraction; dental implants; braces,                   but not limited to the reversal of a vasec-
   crowns, dental orthoses and prostheses; ex-                  tomy or tubal ligation, or any resulting com-
   cept as specifically provided under A. and                   plications, except for medically necessary
   S.;                                                          treatment of medical complications;

6. Experimental or Investigational Procedures.              12. Infertility Services. For any services related
   Experimental or investigational medicine,                    to assisted reproductive technology, includ-
   surgery or other experimental or investiga-                  ing but not limited to the harvesting or
   tional health care procedures as defined, ex-                stimulation of the human ovum, ovum
   cept for services for Members who have                       transplants, in vitro fertilization, Gamete In-
   been accepted into an approved clinical trial                trafallopian Transfer (GIFT) procedure, Zy-
   for cancer as provided under X.;                             gote Intrafallopian Transfer (ZIFT)
                                                                procedure or any other form of induced fer-
    See section entitled “External Independent                  tilization (except for artificial insemination),
    Medical Review” for information concern-                    services or medications to treat low sperm
    ing the availability of a review of services                count or services incident to or resulting
    denied under this exclusion.                                from procedures for a surrogate mother
                                                                who is otherwise not eligible for covered
7. Eye Surgery. For surgery to correct refrac-                  pregnancy and maternity care under a Blue
   tive error (such as but not limited to radial                Shield of California health plan;
   keratotomy, refractive keratoplasty), lenses
   and frames for eyeglasses, contact lenses,               13. Learning Disabilities. For testing for in-
   except as provided under E., and video-                      telligence or learning disabilities;
   assisted visual aids or video magnification
   equipment for any purpose;                               14. Limited or Excluded Services. Benefits
                                                                for services limited or excluded in your
8. Foot Care. For routine foot care, including                  HMO health service plan; however, drugs
   callus, corn paring or excision and toenail                  customarily provided by dentists and oral
   trimming (except as may be provided                          surgeons, or customarily provided for nerv-
                                                                ous or mental disorders, or incident to

                                                      103
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
   pregnancy, or customarily provided for sub-               for any resulting complications and medi-
   stance abuse, or incident to physical therapy             cally necessary services as provided under
   are not excluded;                                         W.;

15. Mental Health. For any services relating to          23. Personal Comfort Items. Convenience
    the diagnosis or treatment of any mental or              items such as telephones, TVs, guest trays,
    emotional illness or disorder that is not a              and personal hygiene items;
    mental health condition;
                                                         24. Physical Examinations. For physical ex-
16. Miscellaneous Equipment. For orthope-                    ams required for licensure, employment, or
    dic shoes except as provided under V., envi-             insurance unless the examination corre-
    ronmental control equipment, generators,                 sponds to the schedule of routine physical
    exercise equipment, self-help/educational                examinations provided under C.;
    devices, vitamins, any type of communica-
    tor, voice enhancer, voice prosthesis, elec-         25. Prescription Orders. Prescription orders
    tronic voice producing machine, or any                   or refills which exceed the amount specified
    other language assistance devices, except as             in the prescription, or prescription orders or
    provided under E. and comfort items;                     refills dispensed more than a year from the
                                                             date of the original prescription.
17. Nutritional and Food Supplements. For
    prescription or non-prescription nutritional             Prescription orders or refills in quantities
    and food supplements except as provided                  exceeding a 30-day supply, except for mail
    under K., and except as provided through a               order.
    hospice agency;
                                                             Prescription orders or refills which are equal
18. Organ Transplants. Incident to an organ                  to or less than the amount of your copay-
    transplant, except as provided under T. and              ment.
    U.;
                                                         26. Private Duty Nursing. In connection with
19. Over-the-Counter Medical Equipment                       private duty nursing, except as provided un-
    or Supplies. For non-prescription (over-                 der A., K. and O.;
    the-counter) medical equipment or supplies
    that can be purchased without a licensed             27. Reading/Vocational Therapy. For or in-
    provider's prescription order, even if a li-             cident to reading therapy; vocational, educa-
    censed provider writes a prescription order              tional, recreational, art, dance or music
    for a non-prescription item, except as spe-              therapy; weight control or exercise pro-
    cifically provided under E., K., O. and V.;              grams; nutritional counseling except as spe-
                                                             cifically provided for under V.;
20. Over-the-Counter Medications. For over-
    the-counter medications not requiring a pre-         28. Reconstructive Surgery. For reconstruc-
    scription, except as provided for smoking                tive surgery and procedures where there is
    cessation drugs;                                         another more appropriate covered surgical
                                                             procedure, or when the surgery or proce-
21. Pain Management. For or incident to                      dure offers only a minimal improvement in
    hospitalization or confinement in a pain                 the appearance of the enrollee (e.g., spider
    management center to treat or cure chronic               veins). In addition, no benefits will be pro-
    pain, except as may be provided through a                vided for the following surgeries or proce-
    participating hospice agency and except as               dures unless for reconstructive surgery:
    medically necessary;
                                                             • Surgery to excise, enlarge, reduce, or
22. Penile Implant. For penile implant devices                 change the appearance of any part of
    and surgery, and any related services except               the body;

                                                   104
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    • Surgery to reform or reshape skin or                     medication), support garments and similar
      bone;                                                    items;
    • Surgery to excise or reduce skin or
      connective tissue that is loose, wrin-               35. Transportation Services. For transporta-
      kled, sagging, or excessive on any part                  tion services other than provided for under
      of the body;                                             H.;
    • Hair transplantation; and
    • Upper eyelid blepharoplasty without                  36. Unapproved Drugs/Medicines. Drugs
      documented significant visual impair-                    and medicines which cannot be lawfully
      ment or symptomatology;                                  marketed without approval of the U.S. Food
                                                               and Drug Administration (FDA); however,
    This limitation shall not apply to breast re-              drugs and medicines which have received
    construction when performed subsequent to                  FDA approval for marketing for one or
    a mastectomy, including surgery on either                  more uses will not be denied on the basis
    breast to achieve or restore symmetry.                     that they are being prescribed for an off-
                                                               label use if the conditions set forth in Cali-
29. Services by Close Relatives. Services per-                 fornia Health & Safety Code Section
    formed by a close relative or by a person                  1367.21 have been met;
    who ordinarily resides in the Member’s
    home;                                                  37. Unauthorized Non-Emergency Services.
                                                               For unauthorized non-emergency services;
30. Sex Transformations. For transgender or
    gender dysphoria conditions, including but             38. Unauthorized Treatment. Not provided,
    not limited to, intersex surgery (transsexual              prescribed, referred, or authorized as de-
    operations), or any related services, or any               scribed herein except for Access+ Specialist
    resulting medical complications, except for                visits, OB/GYN services provided by an
    treatment of medical complications that is                 obstetrician/gynecologist or a family prac-
    medically necessary;                                       tice physician within the same medical
                                                               group or IPA as the Personal Physician,
31. Sexual Dysfunctions. For or incident to                    emergency services or urgent services as
    sexual dysfunctions and sexual inadequacies,               provided under the Agreement provisions,
    except as provided for treatment of organi-                when specific authorization has been ob-
    cally based conditions;                                    tained in writing for such services as de-
                                                               scribed herein, for mental health and
32. Speech Therapy. For or incident to speech                  substance abuse services which must be ar-
    therapy, speech correction or speech pa-                   ranged through the MHSA or for hospice
    thology or speech abnormalities that are not               services received by a participating hospice
    likely the result of a diagnosed, identifiable             agency;
    medical condition, injury or illness, except
    as specifically provided under K., M. and              39. Unlicensed Services. For services pro-
    O.;                                                        vided by an individual or entity that is not li-
                                                               censed or certified by the state to provide
33. Spinal Manipulation. For spinal manipula-                  health care services, or is not operating
    tion or adjustment, except as covered by                   within the scope of such license or certifica-
    Medicare;                                                  tion, except as specifically stated herein;

34. Therapeutic Devices. Devices or appara-                40. Workers’ Compensation/Work-Related Injury.
    tuses, regardless of therapeutic effect (e.g.,             For or incident to any injury or disease aris-
    hypodermic needles and syringes, except as                 ing out of, or in the course of, any employ-
    needed for insulin and covered injectable                  ment for salary, wage or profit if such injury
                                                               or disease is covered by any workers’ com-
                                                               pensation law, occupational disease law or

                                                     105
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    similar legislation. However, if Blue Shield             2. Benefits provided by any other federal or
    provides payment for such services it will be               state governmental agency, or by any county
    entitled to establish a lien upon such other                or other political subdivision, except that
    benefits up to the reasonable cash value of                 this exclusion does not apply to Medi-Cal;
    benefits provided by Blue Shield for the                    or Subchapter 19 (commencing with Section
    treatment of the injury or disease as re-                   1396) of Chapter 7 of Title 42 of the United
    flected by the providers’ usual billed                      States Code; or for the reasonable costs of
    charges;                                                    services provided to the person at a Veter-
                                                                ans Administration facility for a condition
41. Not Specifically Listed as a Benefit.                       unrelated to military service or at a Depart-
                                                                ment of Defense facility, provided the per-
See the Grievance Process section for informa-                  son is not on active duty.
tion on filing a grievance, your right to seek as-
sistance from the Department of Managed                      Exception for Other Coverage
Health Care, and your rights to independent                  A Plan provider may seek reimbursement from
medical review.                                              other third party payors for the balance of its
                                                             reasonable charges for services rendered under
Medical Necessity Exclusion                                  this Plan.
All services must be medically necessary. The
fact that a physician or other provider may pre-             Claims and Services Review
scribe, order, recommend, or approve a service               Blue Shield reserves the right to review all
or supply does not, in itself, make it medically             claims and services to determine if any exclu-
necessary, even though it is not specifically listed         sions or other limitations apply. Blue Shield may
as an exclusion or limitation. Blue Shield may               use the services of physician consultants, peer
limit or exclude benefits for services which are             review committees of professional societies or
not medically necessary.                                     hospitals and other consultants to evaluate
                                                             claims.
Limitations for Duplicate Coverage
In the event that you are covered under the Plan             General Provisions
and are also entitled to benefits under any of the           Grievance Process
conditions listed below, Blue Shield’s liability for         Blue Shield of California has established a griev-
services (including room and board) provided to              ance procedure for receiving, resolving and
the Member for the treatment of any one illness              tracking Members’ grievances with Blue Shield
or injury shall be reduced by the amount of                  of California.
benefits paid, or the reasonable value or the
amount of Blue Shield’s fee-for-service payment              For all services other than mental health
to the provider, whichever is less, of the services
                                                             and substance abuse
provided without any cost to you, because of
your entitlement to such other benefits. This ex-            The Member, a designated representative, or a
clusion is applicable to benefits received from              provider on behalf of the Member, may contact
any of the following sources:                                the Member Services Department by telephone,
                                                             letter or online to request a review of an initial
1. Benefits provided under Title 18 of the So-               determination concerning a claim or service.
   cial Security Act (“Medicare”). If a Member               Members may contact the Plan at the telephone
   receives services to which he is entitled un-             number as noted on the back cover of this
   der Medicare and those services are also                  booklet. If the telephone inquiry to Member
   covered under this Plan, the Plan provider                Services does not resolve the question or issue
   may recover the amount paid for the ser-                  to the Member’s satisfaction, the Member may
   vices under Medicare. This provision does                 request a grievance at that time, which the
   not apply to Medicare Part D (outpatient                  Member Services Representative will initiate on
   prescription drug) benefits.                              the Member’s behalf.


                                                       106
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Note: You may have the right to receive con-                any monies paid on your behalf. To request con-
tinued coverage pending the outcome of your                 tinued coverage during your grievance, contact
grievance. Be advised that, if you qualify for this         Member Services at the telephone number on
continued coverage and if your grievance is de-             your identification card.
nied, you will be held financially responsible for
any monies paid on your behalf. To request con-             The Member, a designated representative, or a
tinued coverage during your grievance, contact              provider on behalf of the Member, may also ini-
Member Services at the telephone number on                  tiate a grievance by submitting a letter or a com-
your identification card.                                   pleted “Grievance Form.” The Member may
                                                            request this form from the MHSA’s Customer
The Member, a designated representative, or a               Service Department. If the Member wishes, the
provider on behalf of the Member, may also ini-             MHSA’s Customer Service staff will assist in
tiate a grievance by submitting a letter or a com-          completing the Grievance Form. Completed
pleted “Grievance Form.” The Member may                     grievance forms must be mailed to the MHSA at
request this form from Member Services. The                 the address provided below. The Member may
completed form should be submitted to Mem-                  also submit the grievance to the MHSA online
ber Services at the address as noted on the back            by visiting http://www.blueshieldca.com.
cover of this booklet. The Member may also
submit the grievance online by visiting our web                             1-877-263-9952
site at http://www.blueshieldca.com.                                   Blue Shield of California
                                                                  Mental Health Service Administrator
Blue Shield will acknowledge receipt of a griev-
                                                                       Attn: Customer Service
ance within 5 calendar days. Grievances are re-
                                                                          P. O. Box 880609
solved within 30 days. The grievance system
                                                                        San Diego, CA 92168
allows Members to file grievances for at least
180 days following any incident or action that is           The MHSA will acknowledge receipt of a griev-
the subject of the Member’s dissatisfaction. See            ance within 5 calendar days. Grievances are re-
the Member Services Department section for in-              solved within 30 days. The grievance system
formation on the expedited decision process.                allows Members to file grievances for at least
                                                            180 days following any incident or action that is
For all mental health and substance                         the subject of the Member’s dissatisfaction. See
abuse services                                              the Member Services Department section for in-
The Member, a designated representative, or a               formation on the expedited decision process.
provider on behalf of the Member, may contact
the MHSA by telephone, letter or online to re-              External Independent Medical Review
quest a review of an initial determination con-             If your grievance involves a claim or services for
cerning a claim or service. Members may                     which coverage was denied by Blue Shield or by
contact the MHSA at the telephone number as                 a contracting provider in whole or in part on the
noted below. If the telephone inquiry to the                grounds that the service is not medically neces-
MHSA’s Customer Service Department does                     sary or is experimental/investigational (including
not resolve the question or issue to the Mem-               the external review available under the Fried-
ber’s satisfaction, the Member may request a                man-Knowles Experimental Treatment Act of
grievance at that time, which the Customer Ser-             1996), you may choose to make a request to the
vice Representative will initiate on the Member’s           Department of Managed Health Care to have
behalf.                                                     the matter submitted to an independent agency
                                                            for external review in accordance with California
Note: You may have the right to receive con-                law. You normally must first submit a grievance
tinued coverage pending the outcome of your                 to Blue Shield and wait for at least 30 days be-
grievance. Be advised that, if you qualify for this         fore you request external review; however, if
continued coverage and if your grievance is de-             your matter would qualify for an expedited deci-
nied, you will be held financially responsible for          sion as described in the Member Services De-


                                                      107
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
partment section or involves a determination                2. Coverage Issues. A coverage issue con-
that the requested service is experimen-                       cerns the denial or approval of health care
tal/investigational, you may immediately request               services substantially based on a finding that
an external review following receipt of notice of              the provision of a particular service is in-
denial. You may initiate this review by complet-               cluded or excluded as a covered benefit un-
ing an application for external review, a copy of              der this Evidence of Coverage booklet. It
which can be obtained by contacting Member                     does not include a plan or contracting pro-
Services. The Department of Managed Health                     vider decision regarding a disputed health
Care will review the application and, if the re-               care service.
quest qualifies for external review, will select an
external review agency and have your records                    If you are dissatisfied with the outcome of
submitted to a qualified specialist for an inde-                Blue Shield’s internal grievance process, you
pendent determination of whether the care is                    may request an administrative review before
medically necessary. You may choose to submit                   the CalPERS Board of Administration, or
additional records to the external review agency                you may choose Small Claims Court, if your
for review. There is no cost to you for this ex-                coverage dispute is within the jurisdictional
ternal review. You and your physician will re-                  limits of Small Claims Court.
ceive copies of the opinions of the external
review agency. The decision of the external re-             3. Malpractice. You must proceed directly to
view agency is binding on Blue Shield; if the ex-              court.
ternal reviewer determines that the service is
medically necessary, Blue Shield will promptly              4. Bad Faith. You must proceed directly to court.
arrange for the service to be provided or the
claim in dispute to be paid. This external review           5. Disputed Health Care Service Issue. A
process is in addition to any other procedures or              disputed health care service issue concerns
remedies available to you and is completely vol-               any health care service eligible for coverage
untary on your part; you are not obligated to re-              and payment under this Evidence of Cover-
quest external review. However, failure to                     age booklet that has been denied, modified,
participate in external review may cause you to                or delayed in whole or in part due to a find-
give up any statutory right to pursue legal action             ing that the service is not medically neces-
against Blue Shield regarding the disputed ser-                sary. A decision regarding a disputed health
vice. For more information regarding the exter-                care service relates to the practice of medi-
nal review process, or to request an application               cine, and includes decisions as to whether a
form, please contact Member Services.                          particular service is experimental or investi-
                                                               gational.
Appeal Procedure Following Disposition
of Plan Grievance Procedure                                     If you are dissatisfied with the outcome of
                                                                Blue Shield’s internal grievance process, you
If no resolution of your complaint is achieved
                                                                may request an administrative review before
by the internal grievance process described
                                                                the CalPERS Board of Administration, or
above, you have several options depending on
                                                                you may proceed to court.
the nature of your complaint.

1. Eligibility Issues. Refer these matters di-
                                                            CalPERS Administrative Appeal Process
   rectly to CalPERS. Contact CalPERS Office                Only issues of eligibility and coverage issues
   of Employer and Member Health Services                   which concern the denial or approval of health
   at P.O. Box 942714, Sacramento, CA                       care services substantially based on a finding
   94229-2714, Fax (916) 795-1277, or tele-                 that the provision of a particular service is in-
   phone CalPERS Customer Service and                       cluded or excluded as a covered benefit under
   Education Division at 888 CalPERS (or                    this Evidence of Coverage booklet may be ap-
   888-225-7377), TTY 1-800-735-2929; (916)                 pealed directly to CalPERS.
   795-3240.

                                                      108
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
CalPERS staff will conduct an administrative                treatment, coverage decisions for treatments that
review upon your appeal of Blue Shield’s denial             are experimental or investigational in nature and
of coverage or the denial of a disputed health              payment disputes for emergency or urgent medi-
care issue by the Department of Managed                     cal services. The Department also has a toll-free
Health Care. However, your written appeal must              telephone number (1-888-HMO-2219) and a
be submitted to CalPERS within 30 days of the               TDD line (1-877-688-9891) for the hearing and
postmark date of Blue Shield’s letter of denial or          speech impaired. The Department’s Web site
the Department of Managed Health Care’s de-                 (http://www.hmohelp.ca.gov) has complaint
termination of findings.                                    forms, IMR application forms and instructions
                                                            online.
If the dispute remains unresolved during the
administrative review process, the matter may               In the event that Blue Shield should cancel or
then proceed to an administrative hearing. Dur-             refuse to renew enrollment for you or your de-
ing the hearing, evidence and testimony will be             pendents and you feel that such action was due
presented to an Administrative Law Judge.                   to health or utilization of benefits, you or your
                                                            dependents may request a review by the De-
To file for an administrative review, contact               partment of Managed Health Care Director.
CalPERS Office of Employer and Member
Health Services, P.O. Box 942714, Sacramento,               Matters of eligibility should be referred directly
CA 94229-2714, Fax (916) 795-1277, or tele-                 to CalPERS - contact CalPERS Office of Em-
phone CalPERS Customer Service and Educa-                   ployer and Member Health Services, P.O. Box
tion Division, 888 CalPERS (or 888-225-7377),               942714, Sacramento, CA 94229-2714.
TTY 1-800-735-2929; (916) 795-3240.
                                                            Alternate Arrangements
If you are covered by Medicare and Medicare                 Blue Shield will make a reasonable effort to se-
has made a decision regarding your appeal of a              cure alternate arrangements for the provision of
Medicare claim determination, you cannot ap-                care by another Plan provider without additional
peal the Medicare decision through the                      expense to you in the event a Plan provider’s
CalPERS Board of Administration.                            contract is terminated, or a Plan provider is un-
                                                            able or unwilling to provide care to you.
Department of Managed Health Care
Review                                                      If such alternate arrangements are not made
The California Department of Managed Health                 available, or are not deemed satisfactory to the
Care is responsible for regulating health care ser-         Board, then Blue Shield will provide all services
vice plans. If you have a grievance against your            and/or benefits of the Agreement to you on a
health plan, you should first telephone your                fee-for-service basis (less any applicable copay-
health plan at 1-800-334-5847 and use your health           ments), and the limitation contained herein with
plan’s grievance process before contacting the              respect to use of a Plan provider shall be of no
Department. Utilizing this grievance procedure              force or effect.
does not prohibit any potential legal rights or
remedies that may be available to you. If you               Such fee-for-service arrangements shall continue
need help with a grievance involving an emer-               until any affected treatment plan has been com-
gency, a grievance that has not been satisfactorily         pleted or until such time as you agree to obtain
resolved by your health plan, or a grievance that           services from another Plan provider, your en-
has remained unresolved for more than 30 days,              rollment is terminated, or your enrollment is
you may call the Department for assistance. You             transferred to another plan administered by the
may also be eligible for an Independent Medical             Board, whichever occurs first. In no case, how-
Review (IMR). If you are eligible for IMR, the              ever, will such fee-for-service arrangements con-
IMR process will provide an impartial review of             tinue beyond the term of the Plan, unless the
medical decisions made by a health plan related to          Extension of Benefits provision applies to you.
the medical necessity of a proposed service or

                                                      109
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Physician-Patient or Plan-Member                           Termination of Group Membership -
Relationship                                               Continuation of Coverage
In the event that Blue Shield of California shall          Termination of Benefits
be unable to establish satisfactory physician-             Coverage for you or your dependents terminates
patient or plan-member relationship with any               at 12:01 a.m. Pacific Time on the earliest of
member, after reasonable efforts to do so, then            these dates: (1) the date the group Agreement is
Blue Shield may either submit the matter for               discontinued, (2) the first day of the month fol-
consideration under Blue Shield's grievance pro-           lowing the month in which the subscriber’s em-
cedures or submit the matter for consideration             ployment terminates, unless a different date has
by the Chief Executive Officer of CalPERS. In              been agreed to between Blue Shield and your
any event, if it is determined that a satisfactory         employer, (3) the end of the period for which
physician-patient or plan-member relationship              the premium is paid, or (4) the first day of the
cannot be maintained, then the member shall be             month following the month in which you or
provided with the opportunity to change en-                your dependents become ineligible. A spouse
rollment to another plan.                                  also becomes ineligible following legal separa-
                                                           tion from the subscriber, entry of a final decree
Advance Directives                                         of divorce, annulment or dissolution of marriage
It is important that you know about your rights            from the subscriber. A domestic partner be-
to make health care decisions on your own be-              comes ineligible upon termination of the do-
half and to execute advance directives. An ad-             mestic partnership.
vance directive is a formal document written by
you in advance of an incapacitating illness or in-         Except as specifically provided under the Exten-
jury. As long as you can speak for yourself,               sion of Benefits and COBRA provisions, there
health care providers will honor your wishes.              is no right to receive benefits for services pro-
But, if you become so ill that you cannot speak            vided following termination of this group
for yourself, then this directive will guide your          Agreement.
health care providers in treating you and will
save your family, friends, and health care pro-            If you cease work because of retirement, disabil-
viders from having to guess what you would                 ity, leave of absence, temporary layoff or termi-
have wanted. We suggest you set aside some                 nation, see your employer about possibly
time to review and discuss your wishes with                continuing group coverage. Also, see the Indi-
your Personal Physician and family members.                vidual Conversion Plan and COBRA and/or
                                                           Cal-COBRA provisions described in this book-
There are three types of advance directives to             let for information on continuation of coverage.
choose from. They are: (1) Durable Power of
Attorney for Health Care (DPAHC), (2) Living               If the subscriber no longer lives or works in the
Wills, and (3) Natural Death Act Declarations.             Plan service area, coverage will be terminated
In California, the preferred document is                   for him and all his dependents. If a dependent
DPAHC, which allows you to appoint an agent                no longer lives or works in the Plan service area,
(family, friend, or other person) whom you trust           then that dependent's coverage will be termi-
to make treatment decisions for you should                 nated. (Special arrangements may be available
there come a time you are unable to make them              for dependents who are full-time students, de-
yourself. You can purchase the DPAHC from a                pendents of subscribers who are required by
stationery store or from the California Medical            court order to provide coverage, and depend-
Association.                                               ents and subscribers who are long-term travel-
                                                           ers. Please contact the Member Services
You should provide copies of your completed                Department to request a brochure which ex-
directive to:     (1) your Personal Physician,             plains these arrangements including how long
(2) your agent, and (3) your family. Be sure to            coverage is available. This brochure is also avail-
keep a copy with you and take a copy to the                able at http://www.blueshieldca.com for HMO
hospital if you are hospitalized for medical care.         Members.)

                                                     110
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
If the relationship between a Plan physician and              which the covered person’s maximum benefits
a Member is unsatisfactory, or if the relationship            are reached, (4) the date on which a replacement
between Blue Shield and a Member is unsatis-                  carrier provides coverage to the person without
factory, then the Member may submit the mat-                  limitation as to the totally disabling condition.
ter to CalPERS under the change of enrollment
procedure in Section 22841 of the Government                  No extension will be granted unless Blue Shield
Code. If the Member does not access the                       receives written certification by a Plan physician
change of enrollment procedure, Blue Shield                   of such total disability within 90 days of the date
will undertake reasonable efforts to make a Plan              on which coverage was terminated, and thereaf-
physician available to the Member with whom a                 ter at such reasonable intervals as determined by
satisfactory relationship may be developed.                   Blue Shield.

In the event any Member believes that his or her              COBRA and/or Cal-COBRA
benefits under this Agreement have been termi-                Please examine your options carefully before
nated because of his or her health status or                  declining this coverage. You should be aware
health requirements, the Member may seek from                 that companies selling individual health insur-
the Department of Managed Health Care, re-                    ance typically require a review of your medical
view of the termination as provided in Califor-               history that could result in a higher premium or
nia Health & Safety Code Section 1365(b).                     you could be denied coverage entirely.

Reinstatement                                                 COBRA
If you cancel or your coverage is terminated, re-             If a Member is entitled to elect continuation of
fer to the CalPERS “Health Program Guide.”                    group coverage under the terms of the Consoli-
                                                              dated Omnibus Budget Reconciliation Act
Cancellation                                                  (COBRA) as amended, the following applies:
No benefits will be provided for services ren-
dered after the effective date of cancellation, ex-           The COBRA group continuation coverage is
cept as specifically provided under the                       provided through federal legislation and allows
Extension of Benefits and Individual Conver-                  an enrolled active or retired employee or his/her
sion Plan and COBRA provisions in this book-                  enrolled family member who lose their regular
let.                                                          group coverage because of certain “qualifying
                                                              events” to elect continuation for 18, 29, or 36
The group Agreement also may be cancelled by                  months.
CalPERS at any time provided written notice is
given to Blue Shield to become effective upon                 An eligible active or retired employee or his/her
receipt, or on a later date as may be specified on            family member(s) is entitled to elect this cover-
the notice.                                                   age provided an election is made within 60 days
                                                              of notification of eligibility and the required
Extension of Benefits                                         premiums are paid. The benefits of the con-
If a person becomes totally disabled while val-               tinuation coverage are identical to the group
idly covered under this Plan and continues to be              plan and the cost of coverage shall be 102% of
totally disabled on the date group coverage ter-              the applicable group premiums rate. No em-
minates, Blue Shield will extend the benefits of              ployer contribution is available to cover the
this Plan, subject to all limitations and restric-            premiums.
tions, for covered services and supplies directly
related to the condition, illness or injury causing           Two “qualifying events” allow enrollees to re-
such total disability until the first to occur of the         quest the continuation coverage for 18 months.
following: (1) the date the covered person is no              The Member's 18-month period may also be ex-
longer totally disabled, (2) 12:01 a.m. on the day            tended to 29 months if the Member was dis-
following a period of 12 months from the date                 abled on or before the date of termination or
group coverage terminated, (3) the date on                    reduction in hours of employment, or is deter-


                                                        111
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
mined to be disabled under the Social Security               3. The enrollee becomes covered by another
Act within the first 60 days of the initial qualify-            health plan without limitations as to pre-
ing event and before the end of the 18-month                    existing conditions, or
period (non-disabled eligible family members
are also entitled to this 29-month extension).               4. The enrollee becomes eligible for Medicare
                                                                benefits, or
1. The covered employee’s separation from
   employment for reasons other than gross                   5. The continuation of coverage was extended
   misconduct.                                                  to 29 months and there has been a final de-
                                                                termination that the Member is no longer
2. Reduction in the covered employee’s hours                    disabled.
   to less than half-time.
                                                             You will receive notice from your employer of
Four “qualifying events” allow an active or re-              your eligibility for COBRA continuation cover-
tired employee’s enrolled family member(s) to                age if your employment is terminated or your
elect the continuation coverage for up to 36                 hours are reduced.
months. Children born to or placed for adop-
tion with the Member during a COBRA con-                     Contact your (former) employing agency or
tinuation period may be added as dependents,                 CalPERS directly if you need more information
provided the employer is properly notified of                about your eligibility for COBRA group con-
the birth or placement for adoption, and such                tinuation coverage.
children are enrolled within 30 days of the birth
or placement for adoption.                                   Cal-COBRA
                                                             COBRA enrollees who became eligible for CO-
1. The employee’s or retiree’s death (and the                BRA coverage on or after January 1, 2003, and
   surviving family member is not eligible for a             who reach the 18-month or 29-month maxi-
   monthly survivor allowance from CalPERS).                 mum available under COBRA, may elect to con-
                                                             tinue coverage under Cal-COBRA for a
2. Divorce or legal separation of the covered                maximum period of 36 months from the date
   employee or retiree from the employee’s or                the Member's continuation coverage began un-
   retiree’s spouse or termination of the do-                der COBRA. If elected, the Cal-COBRA cover-
   mestic partnership.                                       age will begin after the COBRA coverage ends.

3. A dependent child ceases to be a dependent                COBRA enrollees must exhaust all the COBRA
   child.                                                    coverage to which they are entitled before they
                                                             can become eligible to continue coverage under
4. The primary COBRA subscriber becomes                      Cal-COBRA.
   entitled to Medicare.
                                                             In no event will continuation of group coverage
If elected, COBRA continuation coverage is ef-               under COBRA, Cal-COBRA or a combination
fective on the date coverage under the group                 of COBRA and Cal-COBRA be extended for
plan terminates.                                             more than 3 years from the date the qualifying
                                                             event has occurred which originally entitled the
The COBRA continuation coverage will remain                  Member to continue group coverage under this
in effect for the specified time, or until one of            Plan.
the following events terminates the coverage:
                                                             Monthly rates for Cal-COBRA coverage shall be
1. The termination of all employer provided                  110% of the applicable group monthly rates.
   group health plans, or
                                                             Cal-COBRA enrollees must submit monthly
2. The enrollee fails to pay the required pre-               rates directly to Blue Shield. The initial monthly
   mium(s) on a timely basis, or                             rates must be paid within 45 days of the date the

                                                       112
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Member provided written notification to the                3. Provide Blue Shield, the Member’s desig-
Plan of the election to continue coverage and be              nated medical group, and the independent
sent to Blue Shield by first-class mail or other              practice association with a lien in the
reliable means. The monthly rate payment must                 amount of the reasonable costs of benefits
equal an amount sufficient to pay any required                provided, calculated in accordance with
amounts that are due. Failure to submit the cor-              California Civil Code section 3040. The lien
rect amount within the 45-day period will dis-                may be filed with the third party, the third
qualify the Member from continuation coverage.                party’s agent or attorney, or the court unless
                                                              otherwise prohibited by law.
Blue Shield of California is responsible for noti-
fying COBRA enrollees of their right to possibly           A Member’s failure to comply with 1. through
continue coverage under Cal-COBRA at least 90              3., above, shall not in any way act as a waiver,
calendar days before their COBRA coverage will             release, or relinquishment of the rights of Blue
end. The COBRA enrollee should contact Blue                Shield, the Member's designated medical group,
Shield for more information about continuing               or the independent practice association.
coverage. If the enrollee elects to apply for con-
tinuation of coverage under Cal-COBRA, the                 Further, if the Member receives services from a
enrollee must notify Blue Shield at least 30 days          Plan hospital for such injuries, the hospital has
before COBRA termination.                                  the right to collect from the Member the differ-
                                                           ence between the amount paid by Blue Shield
Payment by Third Parties                                   and the hospital’s reasonable and necessary
Third Party Recovery Process and                           charges for such services when payment or re-
the Member’s Responsibility                                imbursement is received by the Member for
If a Member is injured through the act or omis-            medical expenses. The Plan hospital’s right to
sion of another person (a “third party”), Blue             collect shall be in accordance with California
Shield, the Member’s designated medical group,             Civil Code Section 3045.1.
and the independent practice association shall,
with respect to services required as a result of           Workers’ Compensation
that injury, provide the benefits of the Plan and          No benefits are provided for or incident to any
have an equitable right to restitution or other            injury or disease arising out of, or in the course
available remedy to recover the reasonable costs           of, any employment for salary, wage or profit if
of services provided to the Member. The Mem-               such injury or disease is covered by any workers’
ber is required to:                                        compensation law, occupational disease law or
                                                           similar legislation.
1. Notify Blue Shield in writing of any actual
   or potential claim or legal action which such           However, if Blue Shield provides payment for
   Member anticipates bringing or has brought              such services it will be entitled to establish a lien
   against the third party arising from the al-            upon such other benefits up to the reasonable
   leged acts or omissions causing the injury or           cash value of benefits provided by Blue Shield
   illness, not later than 30 days after submit-           for the treatment of the injury or disease as re-
   ting or filing a claim or legal action against          flected by the providers’ usual billed charges.
   the third party; and
                                                           Coordination of Benefits
2. Agree to fully cooperate with Blue Shield,              When a person who is covered under this group
   the Member’s designated medical group,                  Plan is also covered under another group plan,
   and the independent practice association to             or selected group, or blanket disability insurance
   execute any forms or documents needed to                contract, or any other contractual arrangement
   assist them in exercising their equitable right         or any portion of any such arrangement
   to restitution or other available remedies;             whereby the members of a group are entitled to
   and                                                     payment of or reimbursement for hospital or
                                                           medical expenses, such person will not be per-

                                                     113
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
mitted to make a “profit” on a disability by col-              child; then, if that parent has remarried, the
lecting benefits in excess of actual value or cost             plan of the stepparent with custody of the
during any calendar year.                                      child; and finally the plan(s) of the parent(s)
                                                               without custody of the child.
Instead, payments will be coordinated between
the plans in order to provide for “allowable ex-           2. Notwithstanding 1. above, if there is a court
penses” (these are the expenses that are incurred             decree which otherwise establishes financial
for services and supplies covered under at least              responsibility for the medical, dental or
one of the plans involved) up to the maximum                  other health care expenses of the child, then
benefit value or amount payable by each plan                  the plan which covers the child as a depend-
separately.                                                   ent of the parent with that financial respon-
                                                              sibility shall determine its benefits before
If the covered person is also entitled to benefits            any other plan which covers the child as a
under any of the conditions as outlined under                 dependent child.
the Limitations for Duplicate Coverage provi-
sion, benefits received under any such condition           3. If the above rules do not apply, the plan
will not be coordinated with the benefits of this             which has covered the patient for the longer
Plan. The following rules determine the order of              period of time shall determine its benefits
benefit payments:                                             first, provided that:

When the other plan does not have a coordina-                  a. A plan covering a patient as a laid-off or
tion of benefits provision, it will always provide                retired employee, or as a dependent of
its benefits first. Otherwise, the plan covering                  such an employee, shall determine its
the patient as an employee will provide its bene-                 benefits after any other plan covering
fits before the plan covering the patient as a de-                that person as an employee, other than a
pendent.                                                          laid-off or retired employee, or such de-
                                                                  pendent; and,
Except for cases of claims for a dependent child
whose parents are separated or divorced, the                   b. If either plan does not have a provision
plan which covers the dependent child of a per-                   regarding laid-off or retired employees,
son whose date of birth (excluding year of birth)                 which results in each plan determining its
occurs earlier in a calendar year, shall determine                benefits after the other, then the provi-
its benefits before a plan which covers the de-                   sions of a. above shall not apply.
pendent child of a person whose date of birth
(excluding year of birth) occurs later in a calen-         If this Plan is the primary carrier with respect to
dar year. If either plan does not have the provi-          a covered person, then this Plan will provide its
sions of this paragraph regarding dependents,              benefits without reduction because of benefits
which results either in each plan determining its          available from any other plan.
benefits before the other or in each plan deter-
                                                           When this Plan is secondary in the order of
mining its benefits after the other, the provi-
                                                           payments, and Blue Shield is notified that there
sions of this paragraph shall not apply, and the
                                                           is a dispute as to which plan is primary, or that
rule set forth in the plan which does not have
                                                           the primary plan has not paid within a reason-
the provisions of this paragraph shall determine
                                                           able period of time, this Plan will provide the
the order of benefits.
                                                           benefits that would be due as if it were the pri-
1. In the case of a claim involving expenses for           mary plan, provided that the covered person:
   a dependent child whose parents are sepa-               (1) assigns to Blue Shield the right to receive
   rated or divorced, plans covering the child             benefits from the other plan to the extent of the
   as a dependent shall determine their respec-            difference between the value of the benefits
   tive benefits in the following order: First,            which Blue Shield actually provides and the
   the plan of the parent with custody of the              value of the benefits that Blue Shield would
                                                           have been obligated to provide as the secondary

                                                     114
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
plan, (2) agrees to cooperate fully with Blue              If payments have been made by Blue Shield in
Shield in obtaining payment of benefits from               excess of the maximum amount of payment
the other plan, and (3) allows Blue Shield to ob-          necessary to satisfy these provisions, Blue Shield
tain confirmation from the other plan that the             shall have the right to recover the excess from
benefits which are claimed have not previously             any person or other entity to or with respect to
been paid.                                                 whom such payments were made.

If payments which should have been made un-                Blue Shield may release to or obtain from any
der this Plan in accordance with these provi-              organization or person any information which
sions have been made by another Plan, Blue                 Blue Shield considers necessary for the purpose
Shield may pay to the other Plan the amount                of determining the applicability of and imple-
necessary to satisfy the intent of these provi-            menting the terms of these provisions or any
sions. This amount shall be considered as bene-            provisions of similar purpose of any other Plan.
fits paid under this Plan. Blue Shield shall be            Any person claiming benefits under this Plan
fully discharged from liability under this Plan to         shall furnish Blue Shield with such information
the extent of these payments.                              as may be necessary to implement these provi-
                                                           sions.




                                                     115
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
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                                      116
GENERAL INFORMATION FOR ALL MEMBERS
Definitions                                                Custodial or Maintenance Care - care fur-
Access+ Provider - a medical group or IPA,                 nished in the home primarily for supervisory
and all associated physicians and Plan Special-            care or supportive services, or in a facility pri-
ists, that participate in the Access+ HMO Plan             marily to provide room and board or meet the
and for mental health and substance abuse ser-             activities of daily living (which may include nurs-
vices, a MHSA Participating Provider.                      ing care, training in personal hygiene and other
                                                           forms of self care or supervisory care by a phy-
Accidental Injury - definite trauma resulting              sician); or care furnished to a Member who is
from a sudden unexpected and unplanned                     mentally or physically disabled, and
event, occurring by chance, caused by an inde-
pendent external source.                                   1. who is not under specific medical, surgical
                                                              or psychiatric treatment to reduce the dis-
Activities of Daily Living (ADL) - mobility                   ability to the extent necessary to enable the
skills required for independence in normal eve-               patient to live outside an institution provid-
ryday living. Recreational, leisure, or sports ac-            ing such care; or,
tivities are not included.
                                                           2. when, despite such treatment, there is no
Agreement - see Group Health Service Agree-                   reasonable likelihood that the disability will
ment.                                                         be so reduced.

Allowed Charges - the amount a Plan provider               Dental Care and Services - services or treat-
agrees to accept as payment from Blue Shield or            ment on or to the teeth or gums whether or not
the billed amount for non-Plan providers (ex-              caused by accidental injury, including any appli-
cept that physicians rendering emergency ser-              ance or device applied to the teeth or gums.
vices and hospitals rendering any services who
are not Plan providers will be paid based on the           Domiciliary Care - care provided in a hospital
reasonable and customary charge, as defined).              or other licensed facility because care in the pa-
                                                           tient’s home is not available or is unsuitable.
Benefits (Covered Services) - those services
which a Member is entitled to receive pursuant             Dues - the monthly prepayment that is made to
to the terms of the Group Health Service                   the Plan on behalf of each Member by the con-
Agreement.                                                 tractholder.

Calendar Year - a period beginning at 12:01                Durable Medical Equipment - equipment de-
a.m. on January 1 and ending at 12:01 a.m. Janu-           signed for repeated use which is medically nec-
ary 1 of the following year.                               essary to treat an illness or injury, to improve
                                                           the functioning of a malformed body member,
Close Relative - the spouse, domestic partner,             or to prevent further deterioration of the pa-
child, brother, sister or parent of a Member.              tient’s medical condition. Durable medical
                                                           equipment includes wheelchairs, hospital beds,
Copayment - the amount that a Member is re-                respirators, and other items that the Plan deter-
quired to pay for specific covered services.               mines are durable medical equipment.

Cosmetic Surgery - surgery that is performed               Emergency Services - services for an unex-
to alter or reshape normal structures of the body          pected medical condition, including a psychiatric
to improve appearance.                                     emergency medical condition, manifesting itself
                                                           by acute symptoms of sufficient severity (includ-
Covered Services (Benefits) - those services               ing severe pain) such that a layperson who pos-
which a Member is entitled to receive pursuant             sesses an average knowledge of health and
to the terms of the Group Health Service                   medicine could reasonably assume that the ab-
Agreement.                                                 sence of immediate medical attention could be
                                                           expected to result in any of the following:

                                                     117
GENERAL INFORMATION FOR ALL MEMBERS
1. placing the Member’s health in serious jeop-            vide hemophilia therapy products and necessary
   ardy;                                                   supplies and services for covered home infusion
                                                           and home intravenous injections by Members.
2. serious impairment to bodily functions; or,
                                                           Hospice or Hospice Agency - an entity which
3. serious dysfunction of any bodily organ or              provides hospice services to terminally ill per-
   part.                                                   sons and holds a license, currently in effect as a
                                                           hospice pursuant to Health and Safety Code
Employer (Contractholder) - any person,                    Section 1747, or a home health agency licensed
firm, proprietary or non-profit corporation,               pursuant to Health and Safety Code Sections
partnership, public agency or association that             1726 and 1747.1 which has Medicare certifica-
has at least two employees and that is actively            tion.
engaged in business or service, in which a bona
fide employer-employee relationship exists, in             Hospital - either 1., 2. or 3. below:
which the majority of employees were employed
within this state, and which was not formed                1. a licensed and accredited health facility
primarily for purposes of buying health care                  which is primarily engaged in providing, for
coverage or insurance.                                        compensation from patients, medical, diag-
                                                              nostic and surgical facilities for the care and
Experimental or Investigational in Nature -                   treatment of sick and injured Members on
any treatment, therapy, procedure, drug or drug               an inpatient basis, and which provides such
usage, facility or facility usage, equipment or               facilities under the supervision of a staff of
equipment usage, device or device usage, or                   physicians and 24 hour a day nursing service
supplies which are not recognized in accordance               by registered nurses. A facility which is prin-
with generally accepted professional medical                  cipally a rest home, nursing home or home
standards as being safe and effective for use in              for the aged is not included; or,
the treatment of the illness, injury, or condition
at issue. Services which require approval by the           2. a psychiatric hospital licensed as a health fa-
federal government or any agency thereof, or by               cility accredited by the Joint Commission on
any State government agency, prior to use and                 Accreditation of Health Care Organizations;
where such approval has not been granted at the               or,
time the services or supplies were rendered,
shall be considered experimental or investiga-             3. a “psychiatric health facility” as defined in
tional in nature. Services or supplies which                  Section 1250.2 of the Health & Safety Code.
themselves are not approved or recognized in
accordance with accepted professional medical              Independent Practice Association (IPA) - a
standards, but nevertheless are authorized by              group of physicians with individual offices who
law or by a government agency for use in test-             form an organization in order to contract, man-
ing, trials, or other studies on human patients,           age and share financial responsibilities for pro-
shall be considered experimental or investiga-             viding benefits to Members. For mental health
tional in nature.                                          and substance abuse services, this definition in-
                                                           cludes the MHSA.
Family - the subscriber and all enrolled de-
pendents.                                                  Infertility - the Member must be actively trying
                                                           to conceive and has either: (1) the presence of a
Group Health Service Agreement (Agree-                     demonstrated bodily malfunction recognized by
ment) - the Agreement issued by the Plan to the            a licensed physician as a cause of not being able
contractholder that establishes the services               to conceive; or (2) for women age 35 and less,
Members are entitled to from the Plan.                     failure to achieve a successful pregnancy (live
                                                           birth) after 12 months or more of regular un-
Hemophilia Infusion Provider - a provider                  protected intercourse; or (3) for women over
who has an agreement with Blue Shield to pro-              age 35, failure to achieve a successful pregnancy

                                                     118
GENERAL INFORMATION FOR ALL MEMBERS
(live birth) after 6 months or more of regular             3. If there are two or more medically necessary
unprotected intercourse; or (4) failure to achieve            services that may be provided for the illness,
a successful pregnancy (live birth) after 6 cycles            injury or medical condition, Blue Shield will
of artificial insemination supervised by a physi-             provide benefits based on the most cost-
cian (These initial 6 cycles are not a benefit of             effective service.
this Plan.); or (5) 3 or more pregnancy losses.
                                                           4. Hospital inpatient services which are medi-
Inpatient - an individual who has been admit-                 cally necessary include only those services
ted to a hospital as a registered bed patient and             which satisfy the above requirements, re-
is receiving services under the direction of a                quire the acute bed-patient (overnight) set-
physician.                                                    ting, and which could not have been
                                                              provided in a physician’s office, the outpa-
Intensive Outpatient Care Program - an out-                   tient department of a hospital, or in another
patient mental health (or substance abuse)                    lesser facility without adversely affecting the
treatment program utilized when a patient’s                   patient’s condition or the quality of medical
condition requires structure, monitoring, and                 care.
medical/psychological intervention at least 3
hours per day, 3 times per week.                               Inpatient services which are not medically
                                                               necessary include hospitalization:
Medical Group - an organization of physicians
who are generally located in the same facility                 a. for diagnostic studies that could have
and provide benefits to Members. For mental                       been provided on an outpatient basis; or,
health and substance abuse services, this defini-
tion includes the MHSA.                                        b. for medical observation or evaluation; or,

Medical Necessity (Medically Necessary) -                      c. for personal comfort; or,
                                                               d. in a pain management center to treat or
1. Benefits are provided only for services
                                                                  cure chronic pain; or
   which are medically necessary.
                                                               e. for inpatient rehabilitation that can be
2. Services which are medically necessary in-                     provided on an outpatient basis.
   clude only those which have been estab-
   lished as safe and effective and are furnished          5. Blue Shield reserves the right to review all
   in accordance with generally accepted pro-                 services to determine whether they are
   fessional standards to treat an illness, injury            medically necessary.
   or medical condition, and which, as deter-
   mined by Blue Shield, are:                              Medicare - refers to the program of medical
                                                           care coverage set forth in Title XVIII of the So-
    a. consistent with Blue Shield medical pol-            cial Security Act as amended by Public Law 89-
       icy; and,                                           97 or as thereafter amended.
    b. consistent with the symptoms or diagno-             Member - refers to an employee, annuitant, or
       sis; and,                                           family member as those terms are defined in
                                                           Sections 22760, 22772 and 22775 and domestic
    c. not furnished primarily for the conven-
                                                           partner as defined in Sections 22770 and 22771
       ience of the patient, the attending physi-
                                                           of the Government Code.
       cian or other provider; and,
    d. furnished at the most appropriate level             Mental Health Condition - for the purposes
       which can be provided safely and effec-             of this Plan, means those conditions listed in the
       tively to the patient.                              “Diagnostic & Statistical Manual of Mental Dis-
                                                           orders Version IV” (DSM-IV), except as stated
                                                           herein, and no other conditions. Mental health

                                                     119
GENERAL INFORMATION FOR ALL MEMBERS
conditions include severe mental illnesses and               Out-of-Area Follow-up Care - non-emergent
serious emotional disturbances of a child, but do            medically necessary out-of-area services to evalu-
not include any services relating to the follow-             ate the Member’s progress after an initial emer-
ing:                                                         gency or urgent service.

1. Diagnosis or treatment of substance abuse                 Outpatient - an individual receiving services
   conditions;                                               under the direction of a Plan provider, but not
                                                             as an inpatient.
2. Diagnosis or treatment of conditions repre-
   sented by V Codes in DSM-IV;                              Outpatient Facility - a licensed facility, not a
                                                             physician’s office, or a hospital that provides
3. Diagnosis or treatment of any conditions                  medical and/or surgical services on an outpa-
   listed in DSM-IV with the following codes:                tient basis.

    294.8, 294.9, 302.80 through 302-90, 307.0,              Partial Hospitalization/Day Treatment
    307.3, 307.9, 312.30 through 312.34, 313.9,              Program - a treatment program that may be
    315.2, 315.39 through 316.0.                             free-standing or hospital-based and provides
                                                             services at least 5 hours per day and at least 4
Mental Health Service Administrator                          days per week. Patients may be admitted directly
(MHSA) - Blue Shield of California has con-                  to this level of care, or transferred from acute
tracted with the Plan’s Mental Health Service                inpatient care following acute stabilization.
Administrator (MHSA). The MHSA is a special-
ized health care service plan licensed by the                Participating Hospice or Participating Hos-
California Department of Managed Health Care,                pice Agency - an entity which: 1) provides
and will underwrite and deliver Blue Shield’s                hospice services to terminally ill Members and
mental health and substance abuse services                   holds a license, currently in effect, as a hospice
through a unique network of MHSA Participat-                 pursuant to Health and Safety Code Section
ing Providers.                                               1747, or a home health agency licensed pursuant
                                                             to Health and Safety Code Sections 1726 and
Mental Health Services - services provided to                1747.1 which has Medicare certification and
treat a mental health condition.                             2) either has contracted with Blue Shield of Cali-
                                                             fornia or has received prior approval from Blue
MHSA Participating Provider - a provider                     Shield of California to provide hospice service
who has an agreement in effect with the MHSA                 benefits pursuant to the California Health and
for the provision of mental health and substance             Safety Code Section 1368.2.
abuse services.
                                                             Personal Physician - a general practitioner,
Occupational Therapy - treatment under the                   board-certified or eligible family practitioner, in-
direction of a physician and provided by a certi-            ternist, obstetrician/gynecologist or pediatrician
fied occupational therapist, utilizing arts, crafts,         who has contracted with the Plan as a Personal
or specific training in daily living skills, to im-          Physician to provide primary care to Members
prove and maintain a patient’s ability to func-              and to refer, authorize, supervise and coordinate
tion.                                                        the provision of all benefits to Members in ac-
                                                             cordance with the Agreement.
Open Enrollment Period - a fixed time period
designated by CalPERS to initiate enrollment or              Personal Physician Service Area - that geo-
change enrollment from one plan to another.                  graphic area served by the Personal Physician's
                                                             medical group or IPA.
Orthosis - an orthopedic appliance or apparatus
used to support, align, prevent or correct de-               Physical Therapy - treatment provided by a
formities or to improve the function of movable              physician or under the direction of a physician
body parts.                                                  and provided by a registered physical therapist,

                                                       120
GENERAL INFORMATION FOR ALL MEMBERS
certified occupational therapist or licensed doc-          Preventive Health Services — mean those
tor of podiatric medicine. Treatment utilizes              primary preventive medical covered services
physical agents and therapeutic procedures, such           provided by a physician, including related labo-
as ultrasound, heat, range of motion testing, and          ratory services, for early detection of disease as
massage, to improve a patient’s musculoskeletal,           specifically listed below:
neuromuscular and respiratory systems.
                                                           1. Evidence-based items or services that have
Physician - an individual licensed and author-                in effect a rating of “A” or “B” in the cur-
ized to engage in the practice of medicine or os-             rent recommendations of the United States
teopathy.                                                     Preventive Services Task Force;

Plan - the Blue Shield Access+ HMO Health                  2. Immunizations that have in effect a recom-
Plan and/or Blue Shield of California.                        mendation from either the Advisory Com-
                                                              mittee on Immunization Practices of the
Plan Hospital - a hospital licensed under appli-              Centers for Disease Control and Prevention,
cable state law contracting specifically with Blue            or the most current version of the Recom-
Shield to provide benefits to Members under                   mended Childhood Immunization Sched-
the Plan.                                                     ule/United States, jointly adopted by the
                                                              American Academy of Pediatrics, the Advi-
Plan Non-Physician Health Care Practitio-                     sory Committee on Immunization Practices,
ner - a health care professional who is not a                 and the American Academy of Family Phy-
physician and has an agreement with one of the                sicians;
contracted IPAs, medical groups, Plan hospitals
or Blue Shield to provide covered services to              3. With respect to infants, children, and ado-
Members when referred by a Personal Physi-                    lescents, evidence-informed preventive care
cian. For all mental health and substance abuse               and screenings provided for in the compre-
services, this definition includes MHSA Partici-              hensive guidelines supported by the Health
pating Providers.                                             Resources and Services Administration;

Plan Provider - a provider who has an agree-               4. With respect to women, such additional pre-
ment with Blue Shield to provide Plan benefits                ventive care and screenings not described in
to Members and a MHSA Participating Pro-                      paragraph 1. as provided for in comprehen-
vider.                                                        sive guidelines supported by the Health Re-
                                                              sources and Services Administration.
Plan Service Area - the designated geographical
area, approved by the CalPERS Board of Ad-                 Preventive health services include, but are not
ministration, within which a Member must live              limited to, cancer screening (including, but not
or work to be eligible for enrollment in this              limited to, colorectal cancer screening, cervical
Plan.                                                      cancer and HPV screening, breast cancer
                                                           screening and prostate cancer screening), osteo-
Plan Specialist - a physician other than a Per-            porosis screening, screening for blood lead lev-
sonal Physician, psychologist, licensed clinical           els in children at risk for lead poisoning, and
social worker, or licensed marriage and family             health education. More information regarding
therapist who has an agreement with Blue Shield            covered preventive health services is available in
to provide services to Members either according            Blue Shield’s Preventive Health Guidelines.
to an authorized referral by a Personal Physi-             The      Guidelines      are     available      at
cian, or according to the Access+ Specialist               http://www.blueshieldca.com/preventive or by
program, or for OB/GYN physician services.                 calling Member Services and requesting that a
For mental health and substance abuse services,            copy be mailed to you.
this definition includes MHSA Participating
Providers.                                                 In the event there is a new recommendation or
                                                           guideline in any of the resources described in

                                                     121
GENERAL INFORMATION FOR ALL MEMBERS
paragraphs 1. through 4. above, the new rec-                 fied respiratory therapist, to preserve or improve
ommendation will be covered as a preventive                  a patient’s pulmonary function.
health service no later than 12 months following
the issuance of the recommendation.                          Serious Emotional Disturbances of a Child -
                                                             refers to individuals who are minors under the
Prosthesis - an artificial part, appliance or de-            age of 18 years who:
vice used to replace or augment a missing or im-
paired part of the body.                                     1. have one or more mental disorders in the
                                                                most recent edition of the Diagnostic and
Reasonable and Customary Charge - in Cali-                      Statistical Manual of Mental Disorders
fornia: The lower of (1) the provider’s billed                  (other than a primary substance use disorder
charge, or (2) the amount determined by the                     or developmental disorder), that results in
Plan to be the reasonable and customary value                   behavior inappropriate for the child’s age
for the services rendered by a non-Plan provider                according to expected developmental
based on statistical information that is updated                norms, and
at least annually and considers many factors in-
cluding, but not limited to, the provider’s train-           2. meet the criteria in paragraph (2) of subdivi-
ing and experience, and the geographic area                     sion (a) of Section 5600.3 of the Welfare
where the services are rendered; outside of Cali-               and Institutions Code. This section states
fornia: The lower of (1) the provider’s billed                  that members of this population shall meet
charge, or, (2) the amount, if any, established by              one or more of the following criteria:
the laws of the state to be paid for emergency
services.                                                        a. As a result of the mental disorder the
                                                                    child has substantial impairment in at
Reconstructive Surgery - surgery to correct or                      least two of the following areas: self-
repair abnormal structures of the body caused                       care, school functioning, family relation-
by congenital defects, developmental abnormali-                     ships, or ability to function in the com-
ties, trauma, infection, tumors or disease to do                    munity; and either of the following has
either of the following: (1) to improve function,                   occurred: the child is at risk of removal
or (2) to create a normal appearance to the ex-                     from home or has already been removed
tent possible, including dental and orthodontic                     from the home or the mental disorder
services that are an integral part of this surgery                  and impairments have been present for
for cleft palate procedures.                                        more than 6 months or are likely to con-
                                                                    tinue for more than 1 year without
Rehabilitation - inpatient or outpatient care                       treatment;
furnished primarily to restore an individual’s
ability to function as normally as possible after a              b. The child displays one of the following:
disabling illness or injury. Rehabilitation services                psychotic features, risk of suicide or risk
may consist of physical therapy, occupational                       of violence due to a mental disorder.
therapy, and/or respiratory therapy and are pro-
                                                             Services - includes medically necessary health
vided with the expectation that the patient has
                                                             care services and medically necessary supplies
restorative potential. Benefits for speech therapy
                                                             furnished incident to those services.
are described in the section on Speech Therapy.
                                                             Severe Mental Illnesses - conditions with the
Residential Care - services provided in a facil-
                                                             following diagnoses: schizophrenia, schizo af-
ity or a free-standing residential treatment center
                                                             fective disorder, bipolar disorder (manic depres-
that provides overnight/extended-stay services
                                                             sive illness), major depressive disorders, panic
for Members who do not qualify for acute care
                                                             disorder, obsessive-compulsive disorder, perva-
or skilled nursing services.
                                                             sive developmental disorder or autism, anorexia
Respiratory Therapy - treatment, under the di-               nervosa, bulimia nervosa.
rection of a physician and provided by a certi-

                                                       122
GENERAL INFORMATION FOR ALL MEMBERS
Skilled Nursing Facility - a facility with a valid         Supplement to Original Medicare Plan - re-
license issued by the California Department of             fers to the supplement of Medicare services by a
Health Services as a “skilled nursing facility” or         Health Maintenance Organization (HMO).
any similar institution licensed under the laws of         Medicare HMO coordinated care plans cover
any other state, territory, or foreign country.            Medicare deductibles and coinsurance charges
                                                           when services are preauthorized or obtained
Special Food Products - a food product which               from HMO contracting providers. Members are
is both of the following:                                  not restricted to the HMO to receive covered
                                                           Medicare services. However, if services are not
1. Prescribed by a physician or nurse practitio-           received through the Blue Shield Access+
   ner for the treatment of phenylketonuria                HMO, the services and charges will not be cov-
   (PKU) and is consistent with the recom-                 ered by the HMO.
   mendations and best practices of qualified
   health professionals with expertise germane             Total Disability -
   to, and experience in the treatment and care
   of, PKU. It does not include a food that is             1. In the case of an employee or Member oth-
   naturally low in protein, but may include a                erwise eligible for coverage as an employee,
   food product that is specially formulated to               a disability which prevents the individual
   have less than one gram of protein per serv-               from working with reasonable continuity in
   ing;                                                       the individual’s customary employment or in
                                                              any other employment in which the individ-
2. Used in place of normal food products,                     ual reasonably might be expected to engage,
   such as grocery store foods, used by the                   in view of the individual’s station in life and
   general population.                                        physical and mental capacity.

Speech Therapy - treatment under the direc-                2. In the case of a dependent, a disability
tion of a physician and provided by a licensed                which prevents the individual from engaging
speech pathologist or speech therapist, to im-                with normal or reasonable continuity in the
prove or retrain a patient’s vocal skills which               individual’s customary activities or in those
have been impaired by diagnosed illness or in-                in which the individual otherwise reasonably
jury.                                                         might be expected to engage, in view of the
                                                              individual’s station in life.
Subacute Care - skilled nursing or skilled reha-
bilitation provided in a hospital or skilled nurs-         Urgent Services - those covered services ren-
ing facility to patients who require skilled care          dered outside of the Personal Physician service
such as nursing services, physical, occupational           area (other than emergency services) which are
or speech therapy, a coordinated program of                medically necessary to prevent serious deteriora-
multiple therapies or who have medical needs               tion of a Member's health resulting from un-
that require daily Registered Nurse monitoring.            foreseen illness, injury or complications of an
A facility which is primarily a rest home, conva-          existing medical condition, for which treatment
lescent facility or home for the aged is not in-           cannot reasonably be delayed until the Member
cluded.                                                    returns to the Personal Physician service area.

Substance Abuse Condition - for the pur-                   Members Rights and Responsibilities
poses of this Plan, means any disorders caused             You, as a Blue Shield Access+ HMO Plan
by or relating to the recurrent use of alcohol,            Member, have the right to:
drugs, and related substances, both legal and il-
legal, including but not limited to, dependence,           1. Receive considerate and courteous care,
intoxication, biological changes and behavioral               with respect for your right to personal pri-
changes.                                                      vacy and dignity;



                                                     123
GENERAL INFORMATION FOR ALL MEMBERS
2. Receive information about all health ser-             13. Communicate with and receive information
   vices available to you, including a clear ex-             from Member Services in a language you
   planation of how to obtain them;                          can understand;

3. Receive information about your rights and             14. Know about any transfer to another hospi-
   responsibilities;                                         tal, including information as to why the
                                                             transfer is necessary and any alternatives
4. Receive information about your Access+                    available;
   HMO Health Plan, the services we offer
   you, the physicians and other practitioners           15. Obtain a referral from your Personal Physi-
   available to care for you;                                cian for a second opinion;

5. Select a Personal Physician and expect his/           16. Be fully informed about the Blue Shield
   her team of health workers to provide or ar-              grievances procedure and understand how
   range for all the care that you need;                     to use it without fear of interruption of
                                                             health care;
6. Have reasonable access to appropriate
   medical services;                                     17. Voice complaints about the Access+ HMO
                                                             Health Plan or the care provided to you;
7. Participate actively with your physician in
   decisions regarding your medical care. To             18. Participate in establishing public policy of
   the extent permitted by law, you also have                the Blue Shield Access+ HMO, as outlined
   the right to refuse treatment;                            in your Evidence of Coverage and Disclo-
                                                             sure Form or Health Service Agreement.
8. A candid discussion of appropriate or medi-
   cally necessary treatment options for your            You, as a Blue Shield Access+ HMO Plan
   condition, regardless of cost or benefit cov-         Member, have the responsibility to:
   erage;
                                                         1. Carefully read all Blue Shield Access+
9. Receive from your physician an understand-               HMO materials immediately after you are
   ing of your medical condition and any pro-               enrolled so you understand how to use your
   posed appropriate or medically necessary                 benefits and how to minimize your out of
   treatment alternatives, including available              pocket costs. Ask questions when necessary.
   success/outcomes information, regardless                 You have the responsibility to follow the
   of cost or benefit coverage, so you can make             provisions of your Blue Shield Access+
   an informed decision before you receive                  HMO membership as explained in the Evi-
   treatment;                                               dence of Coverage and Disclosure Form or
                                                            Health Service Agreement;
10. Receive preventive health services;
                                                         2. Maintain your good health and prevent ill-
11. Know and understand your medical condi-                 ness by making positive health choices and
    tion, treatment plan, expected outcome and              seeking appropriate care when it is needed;
    the effects these have on your daily living;
                                                         3. Provide, to the extent possible, information
12. Have confidential health records, except                that your physician, and/or the Plan need to
    when disclosure is required by law or per-              provide appropriate care for you;
    mitted in writing by you. With adequate no-
    tice, you have the right to review your              4. Follow the treatment plans and instructions
    medical record with your Personal Physi-                you and your physician have agreed to and
    cian;                                                   consider the potential consequences if you
                                                            refuse to comply with treatment plans or
                                                            recommendations;

                                                   124
GENERAL INFORMATION FOR ALL MEMBERS
5. Ask questions about your medical condition                dignity, and convenience of patients who rely on
   and make certain that you understand the                  the plan’s facilities to provide health care ser-
   explanations and instructions you are given;              vices to them, their families, and the public
                                                             (Health & Safety Code Section 1369).
6. Make and keep medical appointments and
   inform the Plan physician ahead of time                   At least one third of the Board of Directors of
   when you must cancel;                                     Blue Shield is comprised of subscribers who are
                                                             not employees, providers, subcontractors or
7. Communicate openly with the Personal                      group contract brokers and who do not have fi-
   Physician you choose so you can develop a                 nancial interests in Blue Shield. The names of
   strong partnership based on trust and coop-               the members of the Board of Directors may be
   eration;                                                  obtained from:

8. Offer suggestions to improve the Blue                             Sr. Manager, Regulatory Filings
   Shield Access+ HMO Plan;                                          Blue Shield of California
                                                                     50 Beale Street
9. Help Blue Shield to maintain accurate and                         San Francisco, CA 94105
   current medical records by providing timely                       Phone Number: 415-229-5065
   information regarding changes in address,
   family status and other health plan coverage;             Please follow these procedures:
10. Notify Blue Shield as soon as possible if you             • Your recommendations, suggestions or
    are billed inappropriately or if you have any               comments should be submitted in writ-
    complaints;                                                 ing to the Director, Consumer Affairs, at
                                                                the above address, who will acknowl-
11. Select a Personal Physician for your new-                   edge receipt of your letter;
    born before birth, when possible, and notify
                                                              • Your name, address, phone number,
    Blue Shield as soon as you have made this
                                                                subscriber number and group number
    selection;
                                                                should be included with each communi-
                                                                cation;
12. Treat all Plan personnel respectfully and
    courteously as partners in good health care;              • The policy issue should be stated so that
                                                                it will be readily understood. Submit all
13. Pay your dues, copayments and charges for                   relevant information and reasons for the
    non-covered services on time;                               policy issue with your letter;
                                                              • Policy issues will be heard at least quar-
14. For all mental health and substance abuse                   terly as agenda items for meetings of the
    services, follow the treatment plans and in-                Board of Directors. Minutes of Board
    structions agreed to by you and the MHSA                    meetings will reflect decisions on public
    and obtain prior authorization for all non-                 policy issues that were considered. If you
    emergency mental health and substance                       have initiated a policy issue, appropriate
    abuse services.                                             extracts of the minutes will be furnished
                                                                to you within 10 business days after the
Public Policy Participation Procedure                           minutes have been approved.
This procedure enables you to participate in es-
tablishing public policy for Blue Shield of Cali-            Confidentiality of Medical Records and
fornia. It is not to be used as a substitute for the         Personal Health Information
grievance procedure, complaints, inquiries or                Blue Shield of California protects the confiden-
requests for information.                                    tiality/privacy of your personal health informa-
                                                             tion. Personal and health information includes
Public policy means acts performed by a plan or              both medical information and individually iden-
its employees and staff to assure the comfort,               tifiable information, such as your name, address,

                                                       125
GENERAL INFORMATION FOR ALL MEMBERS
telephone number or social security number.                   vide information reasonably needed may result
Blue Shield will not disclose this information                in the delay or denial of benefits until the neces-
without your authorization, except as permitted               sary information is received. Any information
by law.                                                       received for this purpose by Blue Shield will be
                                                              maintained as confidential and will not be dis-
A STATEMENT DESCRIBING BLUE                                   closed without your consent, except as other-
SHIELD’S POLICIES AND PROCEDURES                              wise permitted by law.
FOR PRESERVING THE CONFIDENTIAL-
ITY OF MEDICAL RECORDS IS AVAIL-                              Non-Assignability
ABLE AND WILL BE FURNISHED TO YOU                             Benefits of this Plan are not assignable.
UPON REQUEST. Blue Shield’s policies and
procedures regarding our confidentiality/privacy              Facilities
practices are contained in the “Notice of Privacy             The Plan has established a network of physi-
Practices,” which you may obtain either by calling            cians, hospitals, participating hospice agencies
the Member Services Department at the number                  and non-physician health care practitioners in
listed on the back cover of this booklet, or by ac-           your service area.
cessing Blue Shield of California’s internet site lo-
cated at http://www.blueshieldca.com and                      The Personal Physician(s) you and your depend-
printing a copy.                                              ents select will provide telephone access 24
                                                              hours a day, 7 days a week so that you can ob-
If you are concerned that Blue Shield may have                tain assistance and prior approval of medically
violated your confidentiality/privacy rights, or              necessary care. The hospitals in the Plan net-
you disagree with a decision we made about ac-                work provide access to 24-hour emergency ser-
cess to your personal and health information,                 vices. The list of the hospitals, physicians and
you may contact us at:                                        participating hospice agencies in your service
                                                              area indicates the location and phone numbers
Correspondence Address:                                       of these providers. Contact Member Services at
Blue Shield of California Privacy Official                    the number listed on the back cover of this
P.O. Box 272540                                               booklet for information on Plan non-physician
Chico, CA 95927-2540                                          health care practitioners in your Personal Physi-
                                                              cian Service Area.
Toll-Free Telephone:
1-888-266-8080                                                For urgent services when you are within the
                                                              United States, you simply call toll-free 1-800-
Email Address:                                                810-BLUE (2583) 24 hours a day, 7 days a week.
blueshieldca_privacy@blueshieldca.com                         For urgent services when you are outside the
                                                              United States, you can call collect 1-804-673-
Access to Information                                         1177 24 hours a day. We will identify the Blue-
Blue Shield of California may need information                Card Program participating provider closest to
from medical providers, from other carriers or                you. Urgent services when you are outside the
other entities, or from you, in order to adminis-             United States are available through the BlueCard
ter benefits and eligibility provisions of this               Worldwide Network. For urgent services when
Agreement. You agree that any provider or en-                 you are within California, but outside of your
tity can disclose to Blue Shield that information             Personal Physician Service Area, you should
that is reasonably needed by Blue Shield. You                 contact Blue Shield Member Services in accor-
agree to assist Blue Shield in obtaining this in-             dance with the How to Use the Plan section.
formation, if needed, (including signing any nec-             For urgent care services when you are within
essary authorizations) and to cooperate by                    your Personal Physician Service Area, contact
providing Blue Shield with information in your                your Personal Physician or follow instructions
possession. Failure to assist Blue Shield in ob-              provided by your assigned medical group or
taining necessary information or refusal to pro-              IPA.

                                                        126
GENERAL INFORMATION FOR ALL MEMBERS
Independent Contractors                                    Web Site
Plan providers are neither agents nor employees            Blue Shield’s Web site is located at
of the Plan but are independent contractors.               http://www.blueshieldca.com. Members with
Blue Shield of California conducts a process of            Internet access and a Web browser may view
credentialling and certification of all physicians         and download health care information.
who participate in the Access+ HMO network.
However, in no instance shall the Plan be liable           Utilization Review Process
for the negligence, wrongful acts or omissions             State law requires that health plans disclose to
of any person receiving or providing services,             Members and health plan providers the process
including any physician, hospital, or other pro-           used to authorize or deny health care services
vider or their employees.                                  under the plan.

Access+ Satisfaction                                       Blue Shield has completed documentation of
You may provide Blue Shield with feedback re-              this process ("Utilization Review"), as required
garding the service you receive from Plan physi-           under Section 1363.5 of the California Health &
cians. Return the prepaid postcard available               Safety Code.
from Member Services to Blue Shield. If you are
dissatisfied with the service provided during an           To request a copy of the document describing
office visit with a Plan physician, you may re-            this Utilization Review, call the Member Ser-
quest a refund of your office visit copayment, as          vices Department at 1-800-334-5847.
shown in the Summary of Covered Services un-
der Physician Services.




                                                     127
GENERAL INFORMATION FOR ALL MEMBERS
Notice of the Availability of Language Assistance Services




                                              128
GENERAL INFORMATION FOR ALL MEMBERS
Service Area
The service areas and providers of this Plan are identified in the Blue Shield CalPERS HMO Physician
and Hospital Directory. Contact the Plan for up-to-date confirmation. You must live or work in the
service area(s) identified below to enroll in this Plan and to maintain eligibility in this Plan. If you
choose to enroll in the Plan based on your work ZIP code because your home is not within a service
area, you and each enrolled dependent will be obligated to travel to providers located within the service
area you have selected to receive non-emergency care. You, as the subscriber, and each of your enrolled
dependents must select providers within the service area in which you enroll; however, if a dependent
also works within the plan’s service area, that dependent should select a provider which is near his place
of work. A dependent who does not reside within the State of California cannot be enrolled in the Plan,
except for a child covered by a support order.

The intent of this section is to provide flexibility for those CalPERS members who reside in a commu-
nity that is not within the service area of the plan, but where the subscriber works in a nearby commu-
nity that is within the plan’s service area. However, providers cannot effectively coordinate care for
patients who do not reside or work near the provider’s service area, and may decline to accept a mem-
ber due to lack of proximity.

Basic Plan
Alameda County1             Frazier Park              Nevada County1               Alta Loma
 (Entire County Served)     Glennville                 Cedar Ridge                 Amboy
Butte County2               Gorman                     Chicago Park                Angelus Oaks
 (Entire County Served)     Keene                      Grass Valley                Apple Valley
                            Kernville                  Nevada City                 Baker
Contra Costa County1        Lake Isabella                                          Barstow
 (Entire County Served)                                North San Juan
                            Lamont                     Penn Valley                 Big Bear City
El Dorado County1A          Lost Hills                 Rough and Ready             Big Bear Lake
 Cameron Park               Maricopa                   Washington                  Bloomington
 Cool                       McFarland                                              Blue Jay
                                                      Orange County4
 El Dorado Hills            McKittrick                                             Bryn Mawr
                                                         (Entire County Served)
 Georgetown                 Mettler                                                Cedar Glen
 Greenwood                  Mojave                    Placer County1A              Cedarpines Park
 Pilot Hill                 Onyx                       Alta                        Chino
 Rescue                     Rosamond                   Applegate                   Cima
 Shingle Springs            Shafter                    Auburn                      Colton
Fresno County4              Taft                       Bowman                      Crest Park
 (Entire County Served)     Tehachapi                  Colfax                      Crestline
                            Tupman                     Dutch Flat                  Daggett
Glenn County2                                          Foresthill
 (Entire County Served)     Wasco                                                  Edwards
                            Weldon                     Gold Run                    Essex
Humboldt County1            Wofford Heights            Lincoln                     Etiwanda
 (Entire County Served)     Woody                      Loomis                      Fawnskin
Imperial County4                                       Meadow Vista                Fontana
                           Kings County4
 (Entire County Served)                                Newcastle                   Forest Falls
                            (Entire County Served)     Penryn
Kern County4               Los Angeles County3                                     Fort Irwin
 Arvin                                                 Rocklin                     George AFB
                            (Entire County Served)     Roseville
 Bakersfield                                                                       Grand Terrace
 Bodfish                   Madera County4              Sheridan                    Green Valley Lake
 Boron                      (Entire County Served)     Stanford Ranch              Guasti
 Buttonwillow              Marin County1               Weimar                      Helendale
 Caliente                   (Entire County Served)    Riverside County4            Hesperia
 California City           Mariposa County2              (Entire County Served)    Highland
 Delano                     (Entire County Served)    Sacramento County1A          Hinkley
 Edison                    Merced County2                (Entire County Served)    Joshua Tree
 Edwards                    (Entire County Served)    San Bernardino County3       Lake Arrowhead
 Fellows                                               Adelanto                    Loma Linda

                                                   129
GENERAL INFORMATION FOR ALL MEMBERS
    Lucerne Valley           Yucaipa                     Lincoln Acres       Warner Springs
    Ludlow                   Yucca Valley                Mira Mesa          San Francisco County1
    Lytle Creek             San Diego County4            Miramar NAS         (Entire County Served)
    Mentone                  Alpine                      Mount Laguna       San Joaquin County1
    Montclair                Bonita                      National City       (Entire County Served)
    Morongo Valley           Bonsall                     North Island NAS
    Mount Baldy                                          Ocean Beach        San Luis Obispo County4
                             Borrego Springs                                 (Entire County Served)
    Mountain Pass            Bostonia                    Oceanside
    Newberry Springs         Boulevard                   Otay Mesa          San Mateo County1
    Nipton                   Camp Pendleton              Pacific Beach       (Entire County Served)
    Ontario                  Campo                       Pala               Santa Barbara County4
    Oro Grande               Cardiff by the Sea          Palomar Mountain    (Entire County Served)
    Patton                   Carlsbad                    Pauma Valley       Santa Clara County1
    Phelan                   Chula Vista                 Pine Valley         (Entire County Served)
    Pinon Hills              Coronado                    Point Loma
    Pioneertown                                          Potrero            Santa Cruz County1
                             Del Mar                                         (Entire County Served)
    Rancho Cucamonga         Descanso                    Poway
    Red Mountain             Dulzura                     Ramona             Solano County1
    Redlands                 El Cajon                    Ranchita            (Entire County Served)
    Rialto                   Encinitas                   Rancho Bernardo    Sonoma County1
    Rimforest                Escondido                   Rancho Santa Fe     (Entire County Served)
    Running Springs          Fallbrook                   San Diego          Stanislaus County2
    San Bernardino           Grossmont                   San Luis Rey        (Entire County Served)
    Skyforest                Guatay                      San Marcos
                                                                            Tulare County4
    Sugarloaf                Imperial Beach              San Ysidro
    Trona                                                Santa Ysabel
                                                                             (Entire County Served)
                             Jamul
    Twentynine Palms                                     Santee             Ventura County3
                             Julian
    Twin Peaks               La Jolla                    Solana Beach        (Entire County Served)
    Upland                   La Mesa                     Spring Valley      Yolo County1
    Victorville              Lakeside                    Tecate              (Entire County Served)
    Wrightwood               Lemon Grove                 Valley Center
    Yermo                    Leucadia                    Vista



Pricing Regions for Contracting Agency Employees and Annuitants
1    San Francisco Bay Area Counties
1A   Sacramento Counties
2    Other Northern California Counties
3    Los Angeles/San Bernardino/Ventura Counties
4    Other Southern California Counties




                                                   130
GENERAL INFORMATION FOR ALL MEMBERS
Supplement to Original Medicare Plan
Alameda County               Lake Isabella            Riverside County            North Island NAS
 (Entire County Served)      Lost Hills                Blythe                     Ocean Beach
Butte County                 McKittrick               Sacramento County           Oceanside
 (Entire County Served)      Mojave                     (Entire County Served)    Otay Mesa
                             Onyx                                                 Pacific Beach
Contra Costa County          Tehachapi                San Bernardino County       Pala
 (Entire County Served)      Weldon                    Amboy                      Palomar Mountain
El Dorado County                                       Baker                      Pauma Valley
                            Kings County
 Cameron Park                                          Boron                      Pine Valley
                             (Entire County Served)    Cima
 Cool                                                                             Point Loma
                            Madera County              Essex
 El Dorado Hills                                                                  Potrero
                             Ahwahnee                  Fort Irwin
 Georgetown                                                                       Poway
                             Bass Lake                 Ludlow
 Greenwood                                                                        Ramona
                             Fish Camp                 Mountain Pass
 Pilot Hill                                                                       Ranchita
                             North Fork                Nipton
 Rescue                                                                           Rancho Bernardo
                             Oakhurst                  Pioneertown
 Shingle Springs                                                                  Rancho Santa Fe
                             Wishon                    Red Mountain
Fresno County                                                                     San Diego
                            Marin County               Trona                      San Luis Rey
 Big Creek
                             (Entire County Served)   San Diego County            San Marcos
 Cantua Creek
 Coalinga                   Mariposa County            Alpine                     San Ysidro
 Dos Palos                   (Entire County Served)    Bonita                     Santa Ysabel
 Dunlap                     Merced County              Bonsall                    Santee
 Five Points                 (Entire County Served)    Borrego Springs            Solana Beach
 Hume                       Nevada County              Bostonia                   Spring Valley
 Huron                                                 Boulevard                  Tecate
                             Cedar Ridge
 Kingsburg                                             Camp Pendleton             Valley Center
                             Chicago Park
 Lakeshore                                             Campo                      Vista
                             Grass Valley
 Laton                                                 Cardiff by the Sea         Warner Springs
                             Nevada City
 Lemoore                                               Carlsbad                  San Francisco County
                             North San Juan
 Mendota                                               Chula Vista                (Entire County Served)
                             Penn Valley
 Miramonte                                             Coronado
                             Rough and Ready                                     San Joaquin County
 Mono Hot Springs                                      Del Mar
                             Washington                                           (Entire County Served)
 Orange Cove                                           Descanso
                            Placer County              Dulzura                   San Mateo County
 Piedra                      Alta
 Pinuba                                                El Cajon                   (Entire County Served)
                             Applegate                 Encinitas                 Santa Barbara County
 Reedley                     Auburn
Glenn County                                           Escondido                  (Entire County Served)
                             Bowman                    Fallbrook
 (Entire County Served)                                                          Santa Clara County
                             Colfax                    Grossmont
Humboldt County              Dutch Flat                                           (Entire County Served)
                                                       Guatay
 (Entire County Served)      Foresthill                                          Santa Cruz County
                                                       Imperial Beach
Imperial County              Gold Run                                             (Entire County Served)
                                                       Jamul
 (Entire County Served)      Lincoln                   Julian                    Solano County
Kern County                  Loomis                    La Jolla                   (Entire County Served)
                             Meadow Vista              La Mesa                   Sonoma County
 Bodfish
                             Newcastle                 Lakeside                   (Entire County Served)
 Bakersfield 93381, 93382
                             Penryn                    Lemon Grove
 Boron                                                                           Stanislaus County
                             Rocklin                   Leucadia
 California City                                                                  (Entire County Served)
                             Roseville                 Lincoln Acres
 Delano                                                                          Tulare County
                             Sheridan                  Mira Mesa
 Edwards                                                                          (Entire County Served)
                             Stanford Ranch            Miramar NAS
 Fellows
                             Weimar                    Mount Laguna              Yolo County
 Frazier Park
                                                       National City              (Entire County Served)
 Kernville




                                                  131
Notes




 132
This Combined Evidence of Coverage and Disclosure Form
should be retained for your future reference as a Member of
Blue Shield Access+ HMO.

Should you have any questions, please call Member Services at
1-800-334-5847.
                         Blue Shield of California HMO Service Areas
                             By Geographical Cluster and County


                                                                             Rural North
                                                                             Butte
                                                                             Glenn
                                                                             Humboldt
                                                                             Nevada (partial county)



                                                                                              Greater Sacramento
                                                                                              El Dorado (partial county)
                                                                                              Placer (partial county)
                                                                                              Sacramento
                                                                                              Yolo
                                                                                                                  Central Valley
                          North Bay                                                                               Fresno*
                          Marin                                                                                   Kings
                          Solano                                                                                  Madera*
                          Sonoma                                                                                  Mariposa
                                                                                                                  Merced
                              San Francisco                                                                       San Joaquin
                                                                                                                  Stanislaus
                                 East Bay                                                                         Tulare
                                 Alameda
                                 Contra Costa
                                       Peninsula
                                       San Mateo

                                           South Bay
                                           Santa Clara
                                           Santa Cruz

                                                                                  Kern*
                                                                                  (partial county)
                                                    San Luis Obispo*

                                                                        Santa                                     San Bernardino*
                                                                        Barbara                                   (partial county)
                                                                                              Los
                                                                                              Angeles*

                                                                           Ventura*
                                                                                                                        Riverside*
                                                                                            Orange*
                                                                                                               San Diego
                                                                                                               (partial            Imperial
                                                                                                               county)




                                                                                                                                              An Independent Member of the Blue Shield Association
                       * The Supplement to Original Medicare Plan is not available in all or portions of this county.
                       Refer to Section 3, pages 129 – 131, for alphabetical list of all counties in the service areas.
                           Contact the Plan for up-to-date confirmation of service areas and providers.


                                                         Blue Shield of California
                                                                       Access+ HMO

                                                   For inquiries, issues or requests, please contact
                                                                    Member Services:
                                                                  1-800-334-5847
                                                             www.blueshieldca.com/calpers
                                                                  P.O. Box 272520
                                                               Chico, CA 95927-2520




                                                         50 Beale Street, San Francisco, CA 94105

A10778-14-REV (1/11)

				
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