Blue Cross PPO Share plans

PPO Share Plans Individual and Family Health Plans PPO Share Plans Without health coverage, you could pay an average of $9,328 a day in the hospital. Get the protection you need. Designed for: • Those wanting comprehensive coverage with immediate (no deductible) benefits for preventive care, doctors’ office visits and generic prescription drugs • Adults planning a family/needing maternity benefits • Families with school-age children We also offer a variety of dental plans and life insurance. • Access to over 50,000 California network doctors and specialists and over 400 hospitals – so you’re covered just about anywhere • Significant savings to you – because we’ve negotiated lower fees with our network doctors and hospitals, your share of costs is less while you’re paying your deductible and coinsurance • Immediate (no deductible) benefits for preventive care, doctors’ office visits and generic prescription drugs 1 PPO Share Plans It’s all about balance. These comprehensive PPO plans from Blue Cross of California and BC Life & Health Insurance Company offer just the right balance between costs and benefits. Featuring prescription drug coverage, maternity benefits, doctors’ office visits, hospitalization, professional services, emergency services and preventive care, it’s no wonder that our PPO Share plans are among our most popular. Consider the PPO Share plans if you are planning to have children or are already raising a family – they can also work well if you’re on your own. You have the flexibility to choose from five levels of medical deductibles, and after meeting that deductible, you’ll pay just 30% of the negotiated fee for most covered services. The PPO Share plans let you choose how you want to share in your health coverage costs. The higher your deductible, the lower your premium. Choose the annual deductible/monthly premium balance you’re comfortable with, and enjoy the security of knowing that you have top-of-the-line health coverage. 2 Select the monthly premium you want and get the comprehensive coverage you need. 3 PPO Share 500/1000/1500 Plans These amounts show your share of costs after deductibles, if any Benefit Annual Deductible(s) In-Network Out-of-Network 1 Excludes non-participating charges in excess of the Blue Cross negotiated fee and nonparticipating charges in excess of customary and reasonable fees for emergency care. Copays/coinsurance to participating and nonparticipating providers apply to out-of-pocket maximum except where specifically noted in the policy. $500/$1,000/$1,500 per member (Once 2 members each reach the deductible, the deductible is satisfied for the entire family.) $5,000,000 $5,000/$5,000/$6,000 per member (Once 2 members each reach the maximum, the maximum is satisfied for the entire family.) Lifetime Maximum Annual Out-of-Pocket Maximum1 (includes deductible) Participating and non-participating provider covered services combined Doctors’ Office Visits Professional Services (X-ray, lab, anesthesia, surgeon, etc.) Hospital Inpatient (Overnight Hospital Stays) Hospital Outpatient (If You Don’t Stay Overnight) Emergency Room Services3 Maternity Preventive Care 30% of negotiated fee (deductible waived) 30% of negotiated fee 30% of negotiated fee2 30% of negotiated fee2 30% of negotiated fee 30% of negotiated fee Annual physical exam(s): 30% of negotiated fee* (deductible waived) OR HealthyCheckSM Centers5: $25/$75 copay for basic/premium screening (deductible waived) Routine mammogram, Pap and PSA tests4: 30% of negotiated fee (deductible waived) Well Baby and Well Child (through age 6): 40% of negotiated fee (deductible waived) 50% of negotiated fee plus all excess charges (deductible waived) 50% of negotiated fee plus all excess charges All charges except $650 per day All charges except $380 per day 30% of customary and reasonable fees plus all excess charges 50% of negotiated fee plus all excess charges 2 Additional $500 admission charge at participating hospitals (no additional charge for preferred participating) is for inpatient stays or outpatient surgery or infusion therapy. The charge is not required for ambulatory surgical centers or medical emergencies. 3 Additional $100 copay applies for each emergency room visit. Waived if admitted as inpatient. 4 Tests ordered by a physician are covered, including appropriate screening for breast, cervical and ovarian cancer. 5 One HealthyCheck visit at a HealthyCheck Center only allowed for each 12-month period. HealthyCheck applies only to adults and children age 7 and above. Annual physical exam(s): 50% of negotiated fee* plus all excess charges (deductible waived) 6 Visits to participating and non-participating providers combined. Additional visits may be authorized. Routine mammogram, Pap and PSA tests4: 50% of negotiated fee plus all excess charges (deductible waived) Well Baby and Well Child (through age 6): 50% of negotiated fee plus all excess charges (deductible waived) 50% of negotiated fee plus all excess charges All charges except $25 per visit, up to 12 visits per year6 7 Non-Formulary Drugs: You pay 50% for generic, 100% for brand-name up to the brand-name deductible, then either: 50% if no generic is available, or generic copay plus the difference between brand-name and available generic equivalent. Ambulance Physical and Occupational Therapy; Chiropractic Services Acupuncture/Acupressure Prescription Drugs (Blue Cross Formulary7) Amounts shown are for each 30-day retail or in-network mail order supply 30% of negotiated fee 30% of negotiated fee, up to 12 visits per year6 All charges except $25 per visit, up to 24 visits per year (deductible waived) $10 copay generic; $30 copay brand-name8 after $250 brand-name prescription drug deductible (2-member maximum); 30% of negotiated fee for self-administered injectables, except insulin 50% of drug limited fee schedule and all excess charges plus the copay/coinsurance as stated for in-network benefits; subject to the annual $250 brand-name prescription drug deductible 8 If a member selects a brand-name drug when a generic equivalent drug is available, even if the physician writes a “dispense as written” or “do not substitute” prescription, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug. The amount paid does not apply to the member’s brand-name deductible. * Maximum annual physical exam benefit is $200 for members covered more than 6 months; $100 for members covered less than 6 months. 4 PPO Share 2500 Plan These amounts show your share of costs after deductibles, if any Benefit Annual Deductible(s) Lifetime Maximum Annual Out-of-Pocket Maximum1 (includes deductible) Participating and non-participating provider covered services combined Doctors’ Office Visits Professional Services (X-ray, lab, anesthesia, surgery, etc.) Hospital Inpatient (Overnight Hospital Stays) Hospital Outpatient (If You Don’t Stay Overnight) Emergency Room Services3 Maternity Preventive Care In-Network Out-of-Network 1 Excludes non-participating charges in excess of the Blue Cross negotiated fee and nonparticipating charges in excess of customary and reasonable fees for emergency care. Copays/coinsurance to participating and nonparticipating providers apply to out-of-pocket maximum except where specifically noted in the policy. $2,500 per member (Once 2 members each reach the deductible, the deductible is satisfied for the entire family.) $5,000,000 $7,500 per member (Once 2 members each reach the maximum, the maximum is satisfied for the entire family.) 2 $35 copay (deductible waived) 30% of negotiated fee 30% of negotiated fee 2 50% of negotiated fee plus all excess charges (deductible waived) 50% of negotiated fee plus all excess charges All charges except $650 per day All charges except $380 per day 30% of customary and reasonable fees plus all excess charges 50% of negotiated fee plus all excess charges Additional $500 admission charge at participating hospitals (no additional charge for preferred participating) is for inpatient stays or outpatient surgery or infusion therapy. The charge is not required for ambulatory surgical centers or medical emergencies. Additional $100 copay applies for each emergency room visit. Waived if admitted as inpatient. 3 30% of negotiated fee2 30% of negotiated fee 30% of negotiated fee Annual physical exam(s): 30% of negotiated fee* (deductible waived) OR HealthyCheckSM Centers5: $25/$75 copay for basic/premium screening (deductible waived) Routine mammogram, Pap and PSA tests4: 30% of negotiated fee (deductible waived) Well Baby and Well Child (through age 6): 40% of negotiated fee (deductible waived) 4 Tests ordered by a physician are covered, including appropriate screening for breast, cervical and ovarian cancer. 5 One HealthyCheck visit at a HealthyCheck Center only allowed for each 12-month period. HealthyCheck applies only to adults and children age 7 and above. Annual physical exam(s): 50% of negotiated fee* plus all excess charges (deductible waived) 6 Visits to participating and non-participating providers combined. Additional visits may be authorized. Routine mammogram, Pap and PSA tests4: 50% of negotiated fee plus all excess charges (deductible waived) Well Baby and Well Child (through age 6): 50% of negotiated fee plus all excess charges (deductible waived) 50% of negotiated fee plus all excess charges All charges except $25 per visit, up to 12 visits per year6 7 Non-Formulary Drugs: You pay 50% for generic, 100% for brand-name up to the brand-name deductible, then either: 50% if no generic is available, or generic copay plus the difference between brand-name and available generic equivalent. Ambulance Physical and Occupational Therapy; Chiropractic Services Acupuncture/Acupressure Prescription Drugs (Blue Cross Formulary7) Amounts shown are for each 30-day retail or in-network mail order supply 5 30% of negotiated fee 30% of negotiated fee, up to 12 visits per year6 All charges except $25 per visit, up to 24 visits per year (deductible waived) $10 copay generic; $30 copay brand-name8 after $500 brand-name prescription drug deductible (2-member maximum); 30% of negotiated fee for self-administered injectables, except insulin 50% of drug limited fee schedule and all excess charges plus the copay/coinsurance as stated for in-network benefits; subject to the annual $500 brand-name prescription drug deductible 8 If a member selects a brand-name drug when a generic equivalent drug is available, even if the physician writes a “dispense as written” or “do not substitute” prescription, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug. The amount paid does not apply to the member’s brand-name deductible. * Maximum annual physical exam benefit is $200 for members covered more than 6 months; $100 for members covered less than 6 months. PPO Share 5000 Plan These amounts show your share of costs after deductibles, if any Benefit Excludes non-participating charges in excess of the Blue Cross negotiated fee and nonparticipating charges in excess of customary and reasonable fees for emergency care. Copays/coinsurance to participating and nonparticipating providers apply to out-of-pocket maximum except where specifically noted in the policy. 2 Additional $500 admission charge at participating hospitals (no additional charge for preferred participating) is for inpatient stays or outpatient surgery or infusion therapy. The charge is not required for ambulatory surgical centers or medical emergencies. 1 In-Network Out-of-Network Annual Deductible(s) Lifetime Maximum Annual Out-of-Pocket Maximum1 (includes deductible) Participating and non-participating provider covered services combined Doctors’ Office Visits Professional Services (X-ray, lab, anesthesia, surgeon, etc.) Hospital Inpatient (Overnight Hospital Stays) Hospital Outpatient (If You Don’t Stay Overnight) Emergency Room Services3 Maternity Preventive Care $5,000 per member (Once 2 members each reach the deductible, the deductible is satisfied for the entire family.) $5,000,000 $7,500 per member (Once 2 members each reach the maximum, the maximum is satisfied for the entire family.) $40 copay (deductible waived) 30% of negotiated fee 30% of negotiated fee2 30% of negotiated fee2 30% of negotiated fee 30% of negotiated fee Annual physical exam(s): 30% of negotiated fee* (deductible waived) OR SM 5 HealthyCheck Centers : $25/$75 copay for basic/premium screening (deductible waived) Routine mammogram, Pap and PSA tests4: 30% of negotiated fee (deductible waived) Well Baby and Well Child (through age 6): 40% of negotiated fee (deductible waived) 50% of negotiated fee plus all excess charges (deductible waived) 50% of negotiated fee plus all excess charges All charges except $650 per day All charges except $380 per day 30% of customary and reasonable fees plus all excess charges 50% of negotiated fee plus all excess charges 3 Additional $100 copay applies for each emergency room visit. Waived if admitted as inpatient. 4 Tests ordered by a physician are covered, including appropriate screening for breast, cervical and ovarian cancer. One HealthyCheck visit at a HealthyCheck Center only allowed for each 12-month period. HealthyCheck applies only to adults and children age 7 and above. 6 Visits to participating and non-participating providers combined. Additional visits may be authorized. 5 Annual physical exam(s): 50% of negotiated fee* plus all excess charges (deductible waived) 7 Non-Formulary Drugs: You pay 50% for generic, 100% for brand-name up to the brand-name deductible, then either: 50% if no generic is available, or generic copay plus the difference between brand-name and available generic equivalent. Routine mammogram, Pap and PSA tests4: 50% of negotiated fee plus all excess charges (deductible waived) Well Baby and Well Child (through age 6): 50% of negotiated fee plus all excess charges (deductible waived) 50% of negotiated fee plus all excess charges All charges except $25 per visit, up to 12 visits per year6 If a member selects a brand-name drug when a generic equivalent drug is available, even if the physician writes a “dispense as written” or “do not substitute” prescription, the member will be responsible for the generic copay plus the difference in cost between the brand-name drug and the generic equivalent drug. The amount paid does not apply to the member’s brand-name deductible. * Maximum annual physical exam benefit is $200 for members covered more than 6 months; $100 for members covered less than 6 months. 8 Ambulance Physical and Occupational Therapy; Chiropractic Services Acupuncture/Acupressure Prescription Drugs (Blue Cross Formulary7) Amounts shown are for each 30-day retail or in-network mail order supply 30% of negotiated fee 30% of negotiated fee, up to 12 visits per year6 All charges except $25 per visit, up to 24 visits per year (deductible waived) $10 copay generic; $35 copay brand-name8 after $750 brand-name prescription drug deductible (2-member maximum); 30% of negotiated fee for self-administered injectables, except insulin 50% of drug limited fee schedule and all excess charges plus the copay/coinsurance as stated for in-network benefits; subject to the annual $750 brand-name prescription drug deductible 6 What the Medical Plans Do Not Cover Please take a few moments to review the exclusions and limitations. We want you to understand what your coverage does not include before you enroll. These listings are an overview only. The PPO Share Plans booklets contain a comprehensive list of the plans’ exclusions and limitations. For a sample copy of a Policy/Combined Evidence of Coverage and Disclosure Form (EOC) booklet, ask your agent or contact Blue Cross of California/BC Life & Health Insurance Company. Exclusions and Limitations • Conditions covered by workers’ compensation or similar law. • Experimental or investigative services. • Services provided by a local, state, federal or foreign government, unless you have to pay for them. • Services or supplies not specifically listed as covered under the Policy/EOC. • Services received before your effective date. • Services received after coverage ends. • Services you wouldn’t have to pay for without insurance. • Services from relatives. • Any services received by Medicare benefits without payment of additional premium. • Services or supplies that are not medically necessary. • Routine physical exams, except for preventive care services (e.g., physical exams for insurance, employment, licenses or school are not covered), except as specifically stated in the Policy/EOC. • Any amounts in excess of the maximum amounts listed in the Policy/EOC. • Sex changes. • Cosmetic surgery. • Services primarily for weight reduction except medically necessary treatment of morbid obesity. • Dental care, dental implants or treatment to the teeth, except as specifically stated in the Policy/EOC. • Hearing aids. • Contraceptive drugs and/or certain contraceptive devices, except as specifically stated in the Policy/EOC. • Infertility services. • Private duty nursing. • Eyeglasses or contact lenses, except as specifically stated in the Policy/EOC. • Vision care including certain eye surgeries to replace glasses, except as specifically stated in the Policy/EOC. • Mental and nervous disorders and substance abuse, except as specifically stated in the Policy/EOC. • Certain orthopedic shoes or shoe inserts, except as specifically stated in the Policy/EOC. • Services or supplies related to a preexisting condition. • Outdoor treatment programs. • Telephone or facsimile machine consultations. • Educational services except as specifically provided or arranged by Blue Cross. • Nutritional counseling. • Food or dietary supplements, except for formulas and special food products to prevent complications of phenylketonuria (PKU). • Care or treatment furnished in a non-contracting hospital, except as specifically stated in the Policy/EOC. • Personal comfort items. • Custodial care. • Certain genetic testing. • Outpatient speech therapy, except as specifically stated in the Policy/EOC. • Any amounts in excess of maximums stated in the Policy/EOC. • Services or supplies supplied to any person not covered under the Agreement in connection with a surrogate pregnancy. • Outpatient drugs, medications or other substances dispensed or administered in any outpatient setting. 7 General Provisions Mental Health Coverage Blue Cross of California and BC Life & Health Insurance Company provide the same level of coverage as other medical diagnoses for the medically necessary treatment of severe mental illnesses in persons of any age. Severe mental illness, as defined by the American Psychiatric Association in the Diagnostic and Statistical Manual (DSM), includes the following diagnoses: • Schizophrenia • Schizoaffective disorder • Bipolar disorder (manic-depressive illness) • Major depressive disorders • Panic disorder • Obsessive-compulsive disorder • Pervasive developmental disorder or autism • Anorexia nervosa • Bulimia nervosa Blue Cross also provides the same level of coverage as other medical diagnoses for serious emotional disturbances in children that result in behavior inappropriate to the child’s age, according to expected developmental norms. For the PPO Share 5000, PPO Share 2500 and PPO Share 1500/1000/500 plans, coverage is provided for non-severe mental and nervous disorders and substance abuse as follows: • Inpatient Hospital (30 days/year maximum) – You pay all charges except $175/day • Professional Services (1 visit/day; 20 visits/year maximum) – You pay all charges except $25/visit For more details regarding these benefits, refer to the Policy/Combined Evidence of Coverage and Disclosure Form. Emergency Care Blue Cross covers emergency services necessary to screen and stabilize your condition. No authorization or precertification is required if you reasonably believe an emergency medical condition exists. A medical emergency is an unexpected acute illness, injury or condition that could endanger your health if not treated immediately. Examples of medical emergencies include: • Severe pain • Chest pains • Heavy bleeding • Difficulty breathing or shortness of breath • Sudden loss of consciousness • Sudden weakness or numbness of the face, arm or leg on one side of the body When you consider a medical condition to be an emergency, immediately call 911 or go to the nearest hospital emergency room. Once your condition is stabilized, it is important for the hospital, you or a family member to contact your physician or Blue Cross about the authorization of additional services. 8 Rights and Obligations No-Obligation Review Period After you enroll in a plan offered by Blue Cross of California or BC Life and Health Insurance Company (Blue Cross), you will receive a Policy/EOC booklet that explains the exact terms and conditions of coverage, including the plan’s exclusions and limitations. You have 10 full days to examine your plan’s features. During that time, if you are not fully satisfied, you may decline by returning your Policy/EOC booklet along with a letter notifying us that you wish to discontinue coverage. Policy/EOC booklets are available for you to examine prior to enrolling. Ask your agent or Blue Cross. You may also be eligible for an independent medical review (IMR) of disputed health care services from the Department of Insurance if you believe that BCL&H has improperly denied, modified, or delayed health care services. A disputed health care service is any health care service eligible for coverage and payment under your plan that has been denied, modified or delayed by BCL&H, in whole or in part because the service is not Medically Necessary. The IMR process is in addition to any other procedures or remedies that may be available to you. If you need additional information about IMR or require help in completing the form you may call (818) 234-3353 or you may write to Blue Cross of California/ BC Life & Health Insurance Company P.O. Box 4310 Woodland Hills, CA 91365. Your BCL&H Policy contains an arbitration clause. Disagreements between you and BCL&H which exceed small claims court jurisdictional limits will be resolved through arbitration. To initiate arbitration, a written request must be submitted to your dedicated processing unit who will provide you with information to initiate arbitration. Guarding Your Privacy Blue Cross is fully committed to protecting our members’ privacy. Our complete Notice of Privacy Practices provides a comprehensive overview of the policies and practices we enforce to preserve our members’ privacy rights and control use of their health care information, including: the right to authorize release of information; the right to limit access to medical information; protection of oral, written and electronic information; use of data; and information shared with employers. You may obtain our complete Notice of Privacy Practices from our Web site at www.bluecrossca.com or by calling the Customer Service number listed on your member ID card. Utilization Management and Pre-Service Review The Blue Cross Utilization Management and Pre-Services Review Program helps members receive coverage for appropriate treatment in the appropriate setting. Four review processes are included: 1) Preservice Review assesses medical necessity before services are provided; 2) Admission Review determines at the time of admission if the stay or surgery is Medically Necessary in the event Preservice Review is not conducted; 3) Continued Stay Review determines if a continued stay is Medically Necessary; 4) Retrospective Review determines if the stay or surgery was Medically Necessary after care has been provided if none of the first three reviews were performed. Utilization Management and Pre-Service Review is not the practice of medicine or the provision of medical care to you. Only your doctor can provide you with medical advice and medical care. Department of Managed Health Care The Department of Managed Health Care is responsible for regulating health care service plans, including Blue Cross of California. If you have a grievance against your health plan, you should first telephone your health plan at (800) 333-0912 and use your health plan’s grievance process before contacting the department. Utilizing this grievance procedure does not prohibit any potential legal rights or remedies that may be available to you. If you need help with a grievance involving an emergency, a grievance that has not been satisfactorily resolved by your health plan, or a grievance that has remained unresolved for more than 30 days, you may call the department for assistance. You may also be eligible for an Independent Medical Review (IMR). If you are eligible for an IMR, the IMR process will provide an impartial review of medical decisions made by a health plan related to the medical necessity of proposed service or treatment, coverage decisions for treatments that are experimental or investigational in nature, and payment disputes for emergency or urgent medical services. The department also has a toll-free telephone number (888) HMO-2219 and a TDD line (877) 688-9891 for the hearing and speech impaired. The department’s Internet Web site (www.hmohelp.ca.gov) has complaint forms, IMR application forms and instructions online. Requirement for Binding Arbitration If you are applying for coverage, please note that Blue Cross requires binding arbitration to settle all disputes, including claims of medical malpractice. California Health and Safety Code Section 1363.1 and Insurance Code Section 10123.19 require specified disclosures in this regard, including the following notice: “It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, will be determined by submission to arbitration as provided by California law, and not by a lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.” Both parties also agree to give up any right to pursue on a class basis any claim or controversy against the other. Incurred Medical Care Ratio As required by law, we are advising you that Blue Cross of California and its affiliated companies’ incurred medical care ratio for 2005 was 80.87 percent. This ratio was calculated after provider discounts were applied. California Department of Insurance If you have a problem regarding your coverage, please contact BCL&H to resolve the issue. If you are unable to resolve the matter, you may request a review by the California Deparment of Insurance (CDI) at the following address and telephone number: Department of Insurance, Consumer Affairs Bureau 300 South Spring Street, South Tower Los Angeles, California 90013 1-800-927-HELP (4357). 9 Enrollment Guidelines To enroll, you must be Age 643/4 or younger; A permanent legal resident of California; A U.S. resident for at least the last 3 months; The applicant’s spouse or domestic partner,* age 643/4 or younger; The applicant’s children (under 19 years of age), or the children (under 19 years of age) of the applicant’s enrolling spouse or qualified domestic partner; • The applicant’s unmarried dependent children between the ages of 19 through 22 (“dependent” as defined by the Internal Revenue Service) • • • • • *Spouse includes domestic partner (when applicable). Domestic partner enrollment requires a valid Declaration of Domestic Partnership filed with and stamped by the California Secretary of State, or an equivalent document in accordance with the laws of another jurisdiction recognizing the creation of domestic partnership Medical Underwriting Requirement We believe the cost of our plans should be consistent with a member’s expectant health care needs and risk factors. That’s why Blue Cross offers various levels of coverage. To determine individual medical risk factors, applications are subject to medical underwriting. Depending on the results of underwriting review, a number of things may happen: • You may be offered coverage at the standard premium charge, or • You may be offered the plan you selected at a higher rate, or • You may not qualify for the plan listed in this brochure, or • You may be offered an alternate plan If you have a significant medical condition and do not qualify for the plans in this brochure, or if you have discontinued group coverage, please contact your Blue Cross representative for information regarding other Individual coverage options. Waiting Periods For the PPO Share 5000, PPO Share 2500 and PPO Share 1500/1000/500 plans, there is a specific six-month waiting period for coverage of any condition, disease or ailment for which medical advice or treatment was recommended or received within six months preceding the effective date of coverage. If you apply for coverage within 63 days of terminating your membership with another “creditable” health care plan, then you can use your prior coverage for credit toward the six-month waiting period. Blue Cross will credit the time you were enrolled on the previous plan. Consult with your Blue Cross agent or representative if you have a question about the underwriting process. Terms of Coverage Coverage remains in force as long as you pay the required premiums on time and for as long as you remain eligible for membership. Coverage will cease if you become ineligible because of residency requirements or duplicate Individual coverage with Blue Cross. Blue Cross may change or terminate coverage for all covered persons with the same plan, rating area and deductible (if applicable), including changing rates, with 30 days prior written notice. Blue Cross does not change coverage or rates unless the change applies to all covered persons of the same class. 10 Medical Rating Area Definitions The following indicates the counties and/or ZIP codes for each rating area. The subscriber’s home address determines the rating area. Alameda 95304, 95377, 95391 all other Alameda ZIPs Alpine Amador Butte Calaveras Colusa Contra Costa Del Norte El Dorado Fresno 93245, 93313, 93618 all other Fresno ZIPs Glenn Humboldt Imperial Inyo 93527 all other Inyo ZIPs Kern 93536 93558 all other Kern ZIPs Kings 93242, 93631, 93656 all other Kings ZIPs Lake Lassen Los Angeles Area 2 Area 7 Ar ea 3 Area 1 Area 9 San Benito 93930, 95004 all other San Benito ZIPs San Bernardino 91766, 91792 93516, 93555 all other San Bernardino ZIPs San Diego San Francisco San Joaquin 94514 all other San Joaquin ZIPs San Luis Obispo 93252 93426 all other San Luis Obispo ZIPs Area 7 Area 1 Area 8 Area 9 Area 7 Area 6 Area 6 Area 3 Area 3 Area 2 Area 1 Area 2 Tulare 93631, 93641, 93646, 93654 all other Tulare ZIPs Tuolumne Ventura 90265 and ZIP codes beginning with 913 93252 all other Ventura ZIPs Yolo Yuba 95960 all other Yuba ZIPs Area 2 Area 7 Area 2 Area 5 Area 7 Area 8 Area 3 Area 9 Area 6 Area 7 Sacramento 94571 all other Sacramento ZIPs Area 3 Area 2 Trinity 95526 all other Trinity ZIPs Area 3 Area 1 Area 2 Area 3 Area 2 Area 2 Area 3 Area 2 Area 3 Area 3 Area 1 Area 2 Area 7 Area 2 Area 3 Area 3 Area 6 Area 7 Area 2 Modoc Mono Monterey 93451 95076 all other Monterey ZIPs Area 1 Area 2 Area 8 Area 3 Area 1 Area 3 Area 3 Area 2 Area 9 Area 4 Area 3 Area 2 Area 3 Area 1 Area 4 Area 6 San Mateo Santa Barbara 93252 all other Santa Barbara ZIPs Santa Clara 94303, 95023 all other Santa Clara ZIPs Santa Cruz Shasta Sierra 95922 95960 all other Sierra ZIPs Siskiyou Solano 95690 all other Solano ZIPs Sonoma Stanislaus Sutter 95626, 95648, 95837 all other Sutter ZIPs Tehama 95963, 95973 all other Tehama ZIPs Area 2 Area 7 Area 8 Area 2 Area 3 Area 3 Area 1 Area 3 Area 2 Area 1 Area 1 Area 2 Area 3 Area 3 Area 2 Area 2 Area 3 Area 3 Area 1 Napa Nevada 95977 all other Nevada ZIPs Orange 90638 all other Orange ZIPs Placer 95668, 95692 all other Placer ZIPs Plumas 95981 all other Plumas ZIPs Riverside 92883 all other Riverside ZIPs ZIP codes beginning with 906-912, 915, 917, 918 & 935 except 90623, 90630, 90631, 91709, 93560 90623, 90630, 90631 9 1 70 9 9 3 2 4 3 , 9 3 560 all other Los Angeles ZIP codes Madera Marin Mariposa Mendocino Merced Area 4 Area 6 Ar ea 7 Area 5 Area 2 Area 2 Area 2 Area 3 Area 2 Area 2 Area 3 11 PPO Share 500 (7895/1929) Monthly Rates Effective March 1, 2006 Level 1 Single 19 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Subscriber & Spouse Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 These rates are Level 1 (standard) rates. Rates may be higher based on an individual's underwriting review. NOTE: For the "Subscriber & Spouse" and "Family" categories, rates are based on the age of the younger spouse (or younger domestic partner). In some cases, purchasing separate policies for each member may reduce the premium. For children-only contracts, rates are based on the age of the younger child (and the youngest child will be assigned as the subscriber). Area 1 $225 $298 $325 $391 $438 $563 $681 $742 $501 $578 $663 $778 $873 $1,119 $1,354 $1,447 $507 $564 $590 $571 $619 $747 $867 $885 $720 $852 $896 $985 $1,092 $1,293 $1,529 $1,621 $644 $704 $696 $716 $749 $844 $965 $1,053 $386 $173 $512 $298 $678 $461 Area 2 $208 $271 $301 $344 $387 $474 $581 $651 $459 $533 $609 $690 $803 $997 $1,208 $1,269 $462 $511 $533 $494 $532 $627 $725 $803 $644 $743 $836 $897 $964 $1,160 $1,365 $1,423 $581 $635 $640 $645 $671 $762 $870 $952 $316 $153 $440 $266 $605 $413 Area 3 $197 $256 $281 $327 $368 $462 $562 $643 $434 $498 $584 $678 $799 $963 $1,175 $1,321 $453 $491 $504 $478 $515 $614 $712 $807 $654 $740 $824 $862 $948 $1,147 $1,337 $1,467 $569 $623 $619 $614 $653 $738 $863 $953 $315 $146 $431 $261 $573 $393 Area 4 $212 $275 $304 $391 $438 $563 $682 $743 $476 $572 $645 $778 $873 $1,119 $1,356 $1,458 $488 $540 $564 $571 $619 $747 $867 $892 $710 $854 $888 $991 $1,100 $1,293 $1,530 $1,633 $635 $694 $661 $684 $729 $843 $965 $1,048 $387 $169 $512 $289 $641 $438 Area 5 $228 $298 $334 $391 $438 $563 $693 $776 $494 $607 $714 $830 $967 $1,190 $1,453 $1,516 $518 $570 $601 $571 $619 $747 $867 $944 $728 $854 $971 $1,037 $1,143 $1,409 $1,652 $1,699 $667 $737 $721 $728 $782 $906 $1,051 $1,089 $387 $175 $512 $300 $678 $460 Area 6 $193 $252 $282 $339 $377 $487 $589 $649 $423 $504 $568 $675 $756 $970 $1,173 $1,281 $444 $489 $521 $495 $536 $647 $751 $784 $643 $737 $800 $872 $967 $1,121 $1,325 $1,434 $579 $632 $605 $605 $644 $738 $853 $922 $335 $150 $445 $262 $567 $396 Area 7 $190 $247 $278 $339 $377 $487 $589 $622 $420 $496 $558 $675 $751 $970 $1,173 $1,211 $444 $489 $513 $495 $536 $647 $751 $753 $633 $737 $782 $836 $915 $1,121 $1,325 $1,356 $574 $621 $597 $594 $635 $731 $836 $897 $335 $149 $445 $255 $562 $387 Area 8 $192 $249 $281 $339 $377 $487 $589 $627 $430 $498 $560 $675 $751 $970 $1,173 $1,222 $457 $495 $508 $495 $536 $647 $751 $751 $627 $737 $751 $839 $923 $1,121 $1,325 $1,368 $575 $623 $603 $597 $638 $731 $836 $905 $335 $149 $445 $267 $563 $399 Area 9 $185 $241 $269 $339 $377 $487 $589 $643 $414 $498 $558 $675 $751 $970 $1,173 $1,257 $450 $493 $497 $495 $536 $647 $751 $771 $637 $737 $768 $856 $950 $1,121 $1,325 $1,407 $572 $612 $590 $599 $638 $731 $836 $905 $335 $148 $445 $258 $558 $390 Subscriber & Child Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Family Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Subscriber & Children Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Single Child 0 1 - 18 2 Children 0 1 - 18 3+ Children 0 1 - 18 12 PPO Share 1000 (1393/1930) Monthly Rates Effective March 1, 2006 Level 1 Single 19 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Subscriber & Spouse Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 These rates are Level 1 (standard) rates. Rates may be higher based on an individual's underwriting review. NOTE: For the "Subscriber & Spouse" and "Family" categories, rates are based on the age of the younger spouse (or younger domestic partner). In some cases, purchasing separate policies for each member may reduce the premium. For children-only contracts, rates are based on the age of the younger child (and the youngest child will be assigned as the subscriber). Area 1 $186 $258 $286 $338 $384 $470 $574 $651 $439 $516 $594 $678 $780 $955 $1,160 $1,273 $441 $505 $533 $479 $525 $603 $732 $823 $640 $736 $808 $882 $973 $1,124 $1,319 $1,452 $564 $623 $617 $639 $675 $766 $885 $977 $290 $148 $431 $256 $606 $388 Area 2 $176 $234 $264 $302 $347 $426 $515 $580 $401 $474 $545 $620 $710 $883 $1,038 $1,179 $407 $456 $479 $430 $473 $556 $658 $746 $570 $664 $718 $814 $881 $1,016 $1,187 $1,321 $506 $560 $566 $573 $604 $689 $799 $881 $273 $129 $386 $232 $542 $345 Area 3 $170 $221 $244 $286 $329 $406 $507 $566 $376 $440 $500 $591 $710 $881 $1,073 $1,151 $398 $436 $451 $414 $455 $528 $633 $715 $542 $637 $697 $780 $841 $1,006 $1,204 $1,283 $494 $547 $545 $542 $582 $665 $772 $858 $263 $126 $381 $221 $514 $342 Area 4 $172 $225 $256 $298 $349 $422 $520 $596 $384 $462 $528 $623 $734 $932 $1,086 $1,198 $416 $460 $491 $428 $484 $556 $669 $764 $611 $681 $770 $810 $905 $1,061 $1,285 $1,375 $539 $595 $563 $588 $640 $724 $858 $913 $276 $128 $386 $236 $549 $357 Area 5 $187 $256 $293 $334 $384 $478 $585 $651 $429 $515 $586 $678 $807 $991 $1,171 $1,274 $456 $508 $541 $474 $537 $626 $751 $861 $645 $750 $852 $929 $1,039 $1,175 $1,418 $1,578 $568 $628 $637 $634 $687 $784 $918 $1,013 $289 $147 $434 $258 $600 $403 Area 6 $160 $213 $243 $276 $317 $398 $486 $553 $361 $432 $492 $574 $660 $821 $1,004 $1,105 $384 $430 $462 $398 $439 $515 $620 $704 $563 $637 $710 $758 $843 $994 $1,167 $1,274 $499 $551 $525 $535 $580 $657 $773 $831 $240 $122 $367 $214 $496 $332 Area 7 $157 $209 $239 $271 $310 $390 $476 $536 $357 $431 $486 $561 $652 $801 $971 $1,084 $383 $428 $453 $383 $423 $495 $599 $685 $550 $632 $689 $743 $811 $940 $1,104 $1,218 $493 $538 $515 $514 $557 $633 $743 $813 $238 $120 $352 $211 $485 $326 Area 8 $163 $212 $241 $274 $314 $392 $471 $542 $368 $434 $490 $567 $657 $796 $979 $1,120 $397 $435 $449 $389 $428 $509 $603 $695 $551 $632 $667 $747 $809 $949 $1,113 $1,272 $494 $541 $522 $518 $561 $636 $748 $822 $253 $121 $355 $212 $490 $329 Area 9 $153 $200 $229 $278 $313 $400 $487 $562 $348 $418 $485 $571 $676 $820 $1,008 $1,143 $390 $431 $436 $397 $436 $517 $606 $688 $554 $622 $674 $724 $806 $977 $1,145 $1,259 $490 $529 $508 $521 $565 $641 $742 $806 $263 $115 $360 $211 $480 $318 Subscriber & Child Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Family Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Subscriber & Children Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Single Child 0 1 - 18 2 Children 0 1 - 18 3+ Children 0 1 - 18 13 PPO Share 1500 (7889) Monthly Rates Effective March 1, 2006 Level 1 Single 19 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Subscriber & Spouse Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 These rates are Level 1 (standard) rates. Rates may be higher based on an individual's underwriting review. NOTE: For the "Subscriber & Spouse" and "Family" categories, rates are based on the age of the younger spouse (or younger domestic partner). In some cases, purchasing separate policies for each member may reduce the premium. For children-only contracts, rates are based on the age of the younger child (and the youngest child will be assigned as the subscriber). Area 1 $161 $222 $249 $305 $347 $431 $533 $612 $361 $436 $513 $598 $698 $871 $1,062 $1,179 $374 $424 $452 $428 $459 $540 $656 $746 $561 $655 $726 $802 $886 $1,022 $1,208 $1,369 $485 $544 $544 $569 $604 $691 $808 $899 $251 $129 $387 $206 $537 $322 Area 2 $146 $201 $228 $273 $312 $387 $475 $541 $324 $397 $466 $542 $627 $779 $954 $1,088 $329 $378 $401 $385 $411 $487 $586 $671 $492 $585 $637 $736 $796 $929 $1,100 $1,227 $428 $482 $494 $518 $538 $620 $723 $804 $219 $108 $345 $189 $482 $283 Area 3 $135 $186 $207 $256 $292 $364 $444 $510 $298 $360 $418 $509 $592 $764 $885 $987 $318 $355 $370 $360 $380 $448 $551 $634 $461 $554 $612 $695 $748 $875 $1,037 $1,150 $414 $466 $478 $483 $503 $586 $690 $774 $211 $105 $327 $191 $439 $296 Area 4 $141 $194 $229 $262 $312 $381 $477 $555 $306 $383 $433 $531 $629 $792 $977 $1,101 $336 $380 $411 $370 $412 $478 $590 $698 $531 $589 $672 $713 $804 $925 $1,135 $1,281 $459 $515 $497 $517 $569 $654 $786 $832 $216 $114 $350 $197 $479 $308 Area 5 $158 $219 $255 $302 $347 $438 $543 $611 $348 $434 $503 $598 $717 $893 $1,091 $1,213 $374 $426 $459 $426 $461 $546 $670 $778 $564 $668 $758 $815 $922 $1,064 $1,283 $1,468 $487 $547 $562 $573 $610 $709 $841 $920 $239 $130 $392 $226 $534 $355 Area 6 $132 $186 $218 $249 $285 $360 $446 $515 $286 $356 $415 $498 $581 $739 $940 $1,015 $308 $353 $386 $351 $383 $447 $544 $634 $487 $560 $632 $681 $732 $866 $1,041 $1,180 $424 $475 $473 $474 $507 $592 $703 $755 $197 $109 $319 $186 $439 $287 Area 7 $131 $185 $214 $245 $280 $353 $438 $499 $284 $358 $411 $490 $567 $723 $890 $970 $308 $353 $378 $344 $369 $439 $524 $618 $476 $557 $613 $668 $719 $836 $1,005 $1,139 $419 $464 $462 $463 $494 $570 $680 $739 $198 $107 $310 $176 $431 $272 Area 8 $133 $183 $207 $247 $282 $353 $430 $503 $293 $359 $413 $493 $579 $719 $865 $972 $321 $358 $372 $347 $370 $436 $527 $610 $468 $546 $576 $669 $724 $838 $1,007 $1,113 $418 $465 $463 $466 $496 $572 $681 $745 $204 $107 $317 $186 $435 $291 Area 9 $131 $177 $203 $235 $276 $347 $423 $491 $291 $361 $415 $486 $597 $733 $890 $971 $314 $354 $369 $339 $366 $438 $526 $603 $477 $537 $594 $638 $694 $822 $991 $1,121 $413 $452 $440 $460 $492 $573 $679 $720 $194 $102 $310 $175 $408 $273 Subscriber & Child Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Family Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Subscriber & Children Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Single Child 0 1 - 18 2 Children 0 1 - 18 3+ Children 0 1 - 18 14 PPO Share 2500 (7891) Monthly Rates Effective March 1, 2006 Level 1 Single 19 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Subscriber & Spouse Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 These rates are Level 1 (standard) rates. Rates may be higher based on an individual's underwriting review. NOTE: For the "Subscriber & Spouse" and "Family" categories, rates are based on the age of the younger spouse (or younger domestic partner). In some cases, purchasing separate policies for each member may reduce the premium. For children-only contracts, rates are based on the age of the younger child (and the youngest child will be assigned as the subscriber). Area 1 $112 $161 $186 $247 $291 $373 $474 $556 $268 $344 $422 $508 $607 $783 $942 $1,092 $281 $332 $360 $341 $376 $461 $584 $662 $435 $527 $596 $676 $761 $902 $1,081 $1,252 $355 $414 $410 $448 $494 $577 $696 $779 $192 $97 $317 $165 $427 $259 Area 2 $96 $142 $170 $218 $257 $329 $414 $475 $234 $307 $375 $452 $535 $688 $846 $961 $231 $284 $306 $301 $330 $405 $523 $584 $355 $459 $501 $615 $670 $807 $977 $1,094 $292 $347 $367 $407 $436 $512 $609 $671 $161 $83 $280 $160 $376 $245 Area 3 $88 $127 $141 $201 $238 $304 $382 $448 $209 $268 $326 $418 $498 $647 $770 $890 $229 $264 $270 $279 $310 $381 $493 $540 $325 $381 $414 $573 $621 $749 $910 $1,009 $292 $347 $359 $377 $412 $491 $594 $659 $157 $84 $257 $152 $315 $238 Area 4 $90 $132 $175 $210 $262 $327 $423 $501 $209 $289 $328 $443 $524 $703 $886 $998 $247 $289 $321 $295 $337 $414 $535 $613 $412 $463 $536 $594 $643 $797 $1,019 $1,162 $340 $396 $381 $403 $447 $533 $656 $740 $157 $93 $284 $162 $385 $252 Area 5 $104 $157 $195 $244 $290 $382 $487 $555 $254 $342 $412 $507 $620 $805 $988 $1,102 $282 $334 $366 $343 $395 $476 $612 $671 $435 $539 $601 $695 $752 $944 $1,167 $1,315 $355 $414 $441 $457 $511 $609 $750 $810 $177 $103 $328 $188 $433 $291 Area 6 $80 $128 $164 $198 $239 $309 $387 $456 $189 $260 $320 $410 $490 $648 $799 $910 $212 $260 $297 $273 $317 $373 $483 $564 $369 $437 $506 $562 $608 $744 $919 $1,059 $306 $358 $360 $370 $403 $481 $592 $660 $132 $83 $255 $152 $351 $235 Area 7 $81 $127 $162 $195 $231 $298 $382 $441 $190 $270 $321 $402 $476 $632 $768 $879 $220 $265 $289 $268 $304 $359 $464 $539 $359 $434 $488 $550 $596 $715 $883 $1,016 $302 $347 $346 $363 $388 $468 $569 $629 $138 $82 $250 $148 $345 $225 Area 8 $87 $125 $147 $195 $230 $294 $369 $442 $204 $269 $323 $403 $477 $612 $765 $876 $233 $269 $283 $269 $298 $358 $462 $521 $349 $374 $414 $548 $598 $713 $880 $985 $300 $346 $346 $363 $389 $461 $567 $655 $153 $84 $250 $149 $328 $226 Area 9 $87 $126 $153 $186 $230 $293 $365 $445 $205 $275 $328 $400 $471 $620 $751 $879 $232 $268 $282 $257 $300 $353 $451 $537 $361 $404 $472 $523 $574 $705 $863 $1,001 $300 $337 $335 $353 $385 $464 $553 $638 $149 $81 $251 $143 $339 $222 Subscriber & Child Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Family Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Subscriber & Children Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Single Child 0 1 - 18 2 Children 0 1 - 18 3+ Children 0 1 - 18 15 PPO Share 5000 (H062) Monthly Rates Effective March 1, 2006 Level 1 Single 19 - 29 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Subscriber & Spouse Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 These rates are Level 1 (standard) rates. Rates may be higher based on an individual's underwriting review. NOTE: For the "Subscriber & Spouse" and "Family" categories, rates are based on the age of the younger spouse (or younger domestic partner). In some cases, purchasing separate policies for each member may reduce the premium. For children-only contracts, rates are based on the age of the younger child (and the youngest child will be assigned as the subscriber). Area 1 $75 $104 $122 $170 $205 $276 $356 $395 $163 $222 $261 $345 $422 $567 $723 $779 $183 $200 $221 $231 $271 $345 $426 $468 $270 $325 $357 $433 $497 $639 $818 $857 $249 $261 $266 $301 $337 $412 $509 $519 $130 $71 $207 $115 $257 $175 Area 2 $64 $90 $112 $148 $179 $240 $319 $334 $145 $195 $222 $300 $380 $511 $639 $661 $161 $178 $194 $200 $237 $303 $381 $396 $240 $271 $312 $368 $424 $566 $710 $726 $213 $229 $240 $269 $296 $363 $432 $440 $111 $63 $186 $102 $226 $154 Area 3 $64 $86 $102 $137 $173 $232 $306 $338 $142 $185 $211 $289 $362 $490 $589 $633 $153 $165 $172 $193 $223 $279 $354 $377 $210 $266 $289 $365 $415 $546 $675 $690 $207 $222 $235 $254 $271 $330 $405 $440 $110 $59 $167 $97 $212 $138 Area 4 $65 $90 $115 $150 $195 $259 $339 $372 $150 $195 $220 $313 $382 $522 $692 $736 $163 $190 $207 $209 $244 $312 $402 $435 $214 $274 $299 $386 $432 $564 $766 $816 $228 $244 $255 $287 $322 $395 $487 $495 $111 $68 $174 $109 $219 $163 Area 5 $70 $102 $131 $174 $212 $282 $375 $398 $154 $219 $250 $354 $420 $602 $758 $789 $181 $207 $224 $236 $278 $355 $449 $476 $259 $299 $354 $433 $475 $675 $866 $894 $246 $272 $287 $316 $352 $428 $513 $530 $124 $71 $213 $115 $267 $173 Area 6 $55 $83 $104 $138 $175 $234 $301 $338 $124 $178 $203 $278 $352 $473 $614 $668 $147 $168 $182 $186 $220 $280 $351 $394 $182 $236 $263 $341 $381 $505 $686 $721 $201 $217 $226 $254 $286 $351 $430 $438 $102 $61 $154 $97 $197 $146 Area 7 $59 $82 $101 $134 $170 $228 $293 $330 $134 $177 $202 $274 $342 $459 $596 $653 $146 $168 $181 $182 $213 $273 $349 $393 $194 $253 $275 $347 $392 $518 $668 $719 $198 $213 $220 $253 $278 $340 $425 $436 $100 $61 $156 $97 $202 $146 Area 8 $62 $84 $100 $132 $164 $221 $296 $339 $142 $181 $209 $282 $345 $464 $601 $655 $153 $164 $172 $183 $215 $272 $341 $380 $211 $261 $280 $352 $410 $532 $668 $698 $201 $215 $227 $245 $271 $319 $404 $439 $105 $58 $165 $97 $205 $138 Area 9 $62 $82 $100 $134 $175 $231 $295 $335 $135 $178 $212 $279 $343 $460 $587 $662 $150 $170 $181 $185 $210 $268 $342 $382 $216 $255 $282 $344 $404 $519 $663 $712 $195 $214 $225 $254 $274 $335 $418 $438 $108 $61 $169 $97 $211 $146 Subscriber & Child Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Family Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Subscriber & Children Under 30 30 - 34 35 - 39 40 - 44 45 - 49 50 - 54 55 - 59 60 - 64 Single Child 0 1 - 18 2 Children 0 1 - 18 3+ Children 0 1 - 18 16 Give yourself every advantage – good health, Why Dental Coverage? We believe that a good dental plan should: • Provide quality coverage at affordable rates • Help minimize the cost of expensive dental care • Contribute to your overall health Improve your quality of life, self-confidence and appearance by making good oral health a part of your daily routine and by taking advantage of the benefits offered through our dental plans. Whether you choose the flexibility of our Dental PPO plan from BC Life & Health Insurance Company or comprehensive coverage at a lower cost with our Dental SelectHMOSM plans from Blue Cross of California, you’ll get the benefits you need from a company you can trust. And our rates are so affordable, they’ll make you smile! 17 a bright smile and financial security. Why Term Life Insurance? Losing a loved one is hard enough without having to worry about financial obligations. Families are often unprepared for this sudden loss, and term life insurance can provide financial support and peace of mind at a difficult time. Here are just a few reasons why you’ll want to purchase term life insurance from BC Life & Health Insurance Company: • It’s inexpensive -- just pennies a day • It’s easy -- no additional forms are required to enroll • It’s convenient -- your life and health plan premiums will be on the same bill Help secure your family's future by adding term life insurance to your Blue Cross medical coverage. Term Life Insurance Monthly Rates Age 1-18 19-29 30-39 40-49 50-59 60-65 $15,000 benefit $1.50 $2.80 $3.25 $7.50 $20.90 $29.40 $30,000 benefit $3.00 $5.60 $6.50 $15.00 $41.80 $58.80 $50,000 benefit n/a $9.30 $10.80 $25.00 $69.60 $98.00 For more information on our dental plans or life insurance, ask your Blue Cross agent today! 18 ASK YOUR BLUE CROSS AGENT TODAY. Blue Cross of California (BCC) and BC Life & Health Insurance Company (BCL&H) are Independent Licensees of the Blue Cross Association (BCA). The Blue Cross name and symbol are registered service marks of the BCA. The following plans are offered by BCC: PPO Share 2500/1500/1000/500, Individual HMO, HMO Saver, Select HMO, EPO and Dental SelectHMO. The following plans are offered by BCL&H: Basic PPO 1000/2500, PPO Saver, PPO Share 5000/1000/500, RightPlan PPO 40, 3500 Deductible PPO, PPO 3500 (HSA-Compatible), Short-Term PPO, Tonik, Individual PPO Dental and Term Life. www.bluecrossca.com Rates and benefits effective 3/1/06 11135 5/06 Blue Cross of California Blue Cross of California Commercial HMO/POS Commercial HMO/POSCombined Combined