CalPERS HMO EOC January

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					Effective January 1, 2008




                                      Health Maintenance Organization
                                                                              Access+ HMO              ®




                                               Combined Evidence of Coverage and Disclosure Form
                            for the Basic Plan and the HMO Supplement to Original Medicare Plan




                                                        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 4.
The Supplement to Original Medicare Summary of Covered Services can be found on page 59.

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 95814, 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.
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 de-
scription of their plan beginning on page 6 and members enrolled in the Supplement to Original Medi-
care Plan may find the description of their plan beginning on page 61.

Your interest in the Blue Shield Access+ HMO Health Plan is appreciated. Blue Shield has served Cali-
fornians 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 physicians, hos-
pitals 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 pediatricians. Each of
your eligible family members may also select a Personal Physician. All covered services must be pro-
vided by or arranged through your Personal Physician, except for the following: services received dur-
ing 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, or emergency services, or mental health and substance abuse services. See the Men-
tal Health and Substance Abuse Services paragraphs in the How to Use the Plan section for informa-
tion. Note: A decision will be rendered on all requests for prior authorization of services as follows:
for urgent services, 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
provider 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 possi-
ble, improve your health status. Like you, we believe that maintaining a healthy lifestyle 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 ser-
vice ... 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.

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 Member Services De-
partment through Blue Shield’s toll-free text telephone (TTY) number, 1-800-241-1823.




                                                    1
                                                                                                                               Table of Contents
                                                                                                                                                                    Page
Section 1 - Basic Plan
 Summary of Covered Services ..............................................................................................................4
 Benefit Changes for Current Year .......................................................................................................6
 Eligibility .............................................................................................................................................................6
 Enrollment..........................................................................................................................................................6
 How to Use the Plan.....................................................................................................................................6
   Choice of Physicians and Providers................................................................................................................6
   Payment of Providers........................................................................................................................................6
   Selecting a Personal Physician .........................................................................................................................6
   Role of the Medical Group or IPA.................................................................................................................7
   Changing Personal Physicians or Designated Medical Group or IPA......................................................8
   Continuity of Care by a Terminated Provider...............................................................................................9
   Relationship With Your Personal Physician..................................................................................................9
   How to Receive Care ........................................................................................................................................9
   Use of Personal Physician ................................................................................................................................9
   Obstetrical/Gynecological (OB/GYN) Physician Services .......................................................................9
   Referral to Specialty Services and Second Medical Opinions...................................................................10
   Access+ Specialist............................................................................................................................................11
   Lifepath Advisers.............................................................................................................................................12
   Mental Health and Substance Abuse Services.............................................................................................12
   Emergency Services.........................................................................................................................................13
   Urgent Services ................................................................................................................................................14
   Inpatient, Home Health Care and Other Services .....................................................................................15
   Member Maximum Calendar Year Copayment ..........................................................................................15
   Liability of Member for Payment..................................................................................................................16
   Limitation of Liability .....................................................................................................................................16
   Member Identification Card...........................................................................................................................16
   Member Services Department .......................................................................................................................17
 Rates for Basic Plan ..................................................................................................................................17
   State Employees and Annuitants...................................................................................................................17
   Contracting Agency Employees and Annuitants........................................................................................18
 Benefit Descriptions ..................................................................................................................................19
   Hospital Services..............................................................................................................................................19
   Physician Services (Other Than for Mental Health and Substance Abuse Services)............................20
   Preventive Health Services.............................................................................................................................21
   Diagnostic X-ray/Lab Services......................................................................................................................22
   Durable Medical Equipment, Prostheses and Orthoses and Other Services.........................................22
   Pregnancy and Maternity Care.......................................................................................................................24
   Family Planning and Infertility Services.......................................................................................................24
   Ambulance Services.........................................................................................................................................25
   Emergency Services.........................................................................................................................................25
   Urgent Services ................................................................................................................................................26
   Home Health Care Services, PKU-Related Formulas and Special Food Products, and Home Infusion Therapy .27
   Physical and Occupational Therapy..............................................................................................................28
   Speech Therapy................................................................................................................................................28
   Skilled Nursing Facility Services....................................................................................................................29
   Hospice Program Services..............................................................................................................................29
   Prescription Drugs...........................................................................................................................................32
   Inpatient Mental Health and Substance Abuse Services ...........................................................................37
   Outpatient Mental Health and Substance Abuse Services ........................................................................37

                                                                                  2
Table of Contents
                                                                                                                                                                     Page
  Benefit Descriptions, Continued
    Medical Treatment of the Teeth, Gums, Jaw Joints or Jaw Bones ......................................................... 38
    Special Transplant Benefits ........................................................................................................................... 38
    Organ Transplant Benefits ............................................................................................................................ 39
    Diabetes Care................................................................................................................................................... 39
    Reconstructive Surgery................................................................................................................................... 40
    Clinical Trials for Cancer ............................................................................................................................... 40
    Additional Services ......................................................................................................................................... 41
    Member Maximum Calendar Year Copayment ......................................................................................... 42
  Exclusions and Limitations .................................................................................................................. 42
    General Exclusions and Limitations ............................................................................................................ 42
    Medical Necessity Exclusion......................................................................................................................... 45
    Limitations for Duplicate Coverage............................................................................................................. 46
    Exception for Other Coverage ..................................................................................................................... 46
    Claims and Services Review .......................................................................................................................... 46
  General Provisions .................................................................................................................................... 46
    Grievance Process........................................................................................................................................... 46
    Appeal Procedure Following Disposition of Plan Grievance Procedure .............................................. 48
    CalPERS Administrative Appeal Process ................................................................................................... 48
    Department of Managed Health Care Review ........................................................................................... 49
    Alternate Arrangements ................................................................................................................................. 49
    Physician-Patient or Plan-Member Relationship ....................................................................................... 49
  Termination of Group Membership - Continuation of Coverage ................................... 50
    Termination of Benefits................................................................................................................................. 50
    Reinstatement .................................................................................................................................................. 50
    Cancellation...................................................................................................................................................... 50
    Individual Conversion Plan ........................................................................................................................... 50
    Guaranteed Issue Individual Coverage........................................................................................................ 51
    Extension of Benefits..................................................................................................................................... 51
    COBRA and/or Cal-COBRA....................................................................................................................... 52
    Continuation of Group Coverage After COBRA and/or Cal-COBRA ................................................ 53
  Payment by Third Parties ....................................................................................................................... 54
    Third Party Recovery Process and the Member’s Responsibility............................................................ 54
    Workers’ Compensation ................................................................................................................................ 55
    Coordination of Benefits ............................................................................................................................... 55
Section 2 - Supplement to Original Medicare Plan .................................................. 57
Section 3 - General Information for All Members.................................................... 111
  Definitions ..................................................................................................................................................... 111
   Members Rights and Responsibilities ........................................................................................................ 117
   Public Policy Participation Procedure ....................................................................................................... 118
   Confidentiality of Medical Records and Personal Health Information................................................ 119
   Access to Information.................................................................................................................................. 119
   Non-Assignability ......................................................................................................................................... 119
   Facilities .......................................................................................................................................................... 119
   Independent Contractors............................................................................................................................. 120
   Access+ Satisfaction..................................................................................................................................... 120
   Web Site.......................................................................................................................................................... 120
   Utilization Review Process .......................................................................................................................... 120
   Preventive Health Guidelines ..................................................................................................................... 121
  Service Area ................................................................................................................................................. 126

                                                                                   3
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
Physician Services & Preventive Health
    Office/Home Visits                                                     $15/visit
    Allergy Testing/Treatment                                             No Charge
    Inpatient Hospital Visits                                             No Charge
    Surgery/Anesthesia                                                    No Charge
    Periodic Health Exam                                                  No Charge
    Well Baby Care                                                        No Charge
    Gynecological Exam                                                    No Charge
    Immunization/Inoculation                                              No Charge
    Vision Screening                                                      No Charge
    Hearing Exam/Testing                                                  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 - waived if hospitalized or kept for
Emergency Care/Services                                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




                                                   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
                                                         $5 generic, $15 brand name, $45 non-
                                                         Formulary/prescription - not to exceed a 30-
Prescription Drugs                                       day supply for short-term or acute illness.
                                                         $10 generic, $25 brand name, $75 non-
                                                         Formulary/prescription - not to exceed a 90-
                                                         day supply for mail order drugs which are taken
                                                         over long periods of time (maintenance drugs);
                                                         $1,000 out-of-pocket annual maximum.
Mental Health
  Inpatient                                                                   No Charge
    Outpatient                                           $20/visit - up to 20 visits per calendar year for
                                                         other than severe mental illnesses or serious
   The Member copayment for the initial visit to de-
                                                         emotional disturbances of a child.
   termine the condition and diagnosis of the Mem-
   ber (except for Access+ Specialist visits, which      $15/visit for severe mental illnesses or serious
   require a $30 copayment per visit) will be $15 per    emotional disturbances of a child.
   visit. Access+ Specialist visits will accrue toward
   the 20 visit per calendar year maximum.
Substance Abuse
   Inpatient (limited to acute medical detoxification                         No Charge
   only)
    Outpatient                                           $15/visit - up to 20 visits per calendar year.
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.


                                                   5
BASIC PLAN
Benefit Changes                                         CalPERS at the address or telephone number
for Current Year                                        shown below:
Office Visit Copayment
                                                        CalPERS Office of Employer and Member
The office visit copayment is changed to $15. The
                                                        Health Services, P.O. Box 942714, Sacramento,
preventive care copayment is waived.
                                                        CA 94229-2714, Fax (916) 795-1277
Urgent Services                                         CalPERS Customer Service and Education Di-
The urgent services copayment is changed to $15.        vision
                                                             Toll free 1-888 CalPERS (or 888-225-7377)
Out-of-Pocket Maximum                                        TTY 1-800-735-2929; (916) 795-3240
There is an annual out-of-pocket maximum of
$1,500 per individual and $3,000 per family.            Benefits of this Plan become effective at 12:01
                                                        a.m. Pacific Time on the eligibility date estab-
BENEFITS OF THIS PLAN ARE AVAIL-                        lished by CalPERS.
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 RE-
DUCTION      IN    BENEFITS    OR
                                                        How to Use the Plan
ELIMINATION OF BENEFITS) APPLY TO
SERVICES OR SUPPLIES FURNISHED ON                       Choice of Physicians and Providers
OR AFTER THE EFFECTIVE DATE OF                          PLEASE READ THE FOLLOWING IN-
MODIFICATION. THERE IS NO VESTED                        FORMATION SO YOU WILL KNOW
RIGHT TO RECEIVE THE BENEFITS OF                        FROM WHOM OR WHAT GROUP OF
THIS PLAN.                                              PROVIDERS HEALTH CARE MAY BE
                                                        OBTAINED.
Eligibility
Information pertaining to your eligibility, en-         Payment of Providers
rollment, cancellation or termination of cover-         Blue Shield generally contracts with groups of
age, conversion rights, etc. can be found in the        physicians to provide services to Members. A
CalPERS informational booklet “Health Pro-              fixed, monthly fee is paid to these groups of
gram Guide.” The booklet is prepared by                 physicians for each Member whose Personal
CalPERS Office of Employer and Member                   Physician is in the group. This payment system,
Health Services in Sacramento. A copy of this           capitation, includes incentives to the groups of
booklet can be ordered using the postage-paid           physicians to manage all services provided to
order card included in the Open Enrollment              Members in an appropriate manner consistent
mailing, through the CalPERS Web site                   with the Agreement.
(http://www.calpers.ca.gov),       by     calling
CalPERS, or by contacting your Health Benefits          If you want to know more about this payment
Officer.                                                system, contact Member Services at the number
                                                        listed on the back cover of this booklet or talk
Remember, it is your responsibility to stay in-         to your Plan provider.
formed about your coverage. If you have any
questions, consult your Health Benefits Officer         Selecting a Personal Physician
in your agency or the retirement system from            A close physician-to-patient relationship is an
which you receive your allowance, or contact            important ingredient that helps to ensure the

                                                    6
BASIC PLAN
best medical care. Each Member is therefore re-          group or IPA as the mother’s Personal Physi-
quired to select a Personal Physician at the time        cian when the newborn is the natural child of
of enrollment. Family members can choose dif-            the mother. If the mother of the newborn is not
ferent Personal Physicians in different medical          enrolled as a Member or if the child has been
groups or IPAs, except as described for new-             placed with the subscriber for adoption, the
borns below. This decision is an important one           Personal Physician selected must be a physician
because your Personal Physician will:                    in the same medical group or IPA as the sub-
                                                         scriber. If you do not select a Personal Physician
 • Help you decide on actions to maintain                within 31 days following the birth or placement
   and improve your total health;                        for adoption, the Plan will designate a Personal
 • Coordinate and direct all of your medical             Physician from the same medical group or IPA
   care needs;                                           as the natural mother or the subscriber. This
 • Authorize emergency services when ap-                 designation will remain in effect for the first cal-
   propriate;                                            endar month during which the birth or place-
 • Work with your medical group or IPA to                ment for adoption occurred. If you want to
   arrange your referrals to specialty physi-            change the Personal Physician for the child after
   cians, hospitals and all other health ser-            the month of birth or placement for adoption,
   vices, including requesting any prior                 see the section below on Changing Personal
   authorization you will need;                          Physicians or Designated Medical Group or
 • Prescribe those lab tests, x-rays and ser-            IPA. If your child is ill during the first month of
   vices you require;                                    coverage, be sure to read the information about
 • If you request it, assist you in obtaining            changing Personal Physicians during a course of
   prior approval from the Mental Health                 treatment or hospitalization.
   Services Administrator (MHSA) for
   mental health and substance abuse ser-                Remember that if you want your child covered
   vices. See the Mental Health and Sub-                 beyond the 31 days from the date of birth or
   stance Abuse Services paragraphs in the               placement for adoption, you should contact
   How to Use the Plan section for infor-                CalPERS Office of Employer and Member
   mation; and,                                          Health Services and Blue Shield to add your
 • Assist you in applying for admission into             child to your coverage.
   a hospice program through a participat-
   ing hospice agency when necessary.
                                                         Role of the Medical Group or IPA
                                                         Most Blue Shield Access+ HMO Personal Phy-
To ensure access to services, each Member must           sicians contract with medical groups or IPAs to
select a Personal Physician who is located suffi-        share administrative and authorization responsi-
ciently close to the Member’s home or work ad-           bilities with them. (Of note, some Personal Phy-
dress to ensure reasonable access to care, as            sicians contract directly with Blue Shield.) Your
determined by Blue Shield. If you do not select          Personal Physician coordinates with your desig-
a Personal Physician at the time of enrollment,          nated medical group or IPA to direct all of your
the Plan will designate a Personal Physician for         medical care needs and refer you to specialists
you and you will be notified of the name of the          or hospitals within your designated medical
designated Personal Physician. This designation          group or IPA unless because of your health
will remain in effect until you notify the Plan of       condition, care is unavailable within the medical
your selection of a different Personal Physician.        group or IPA.

A Personal Physician must also be selected for a         Your designated medical group or IPA (or Blue
newborn or child placed for adoption, prefera-           Shield when noted on your identification card)
bly prior to birth or adoption, but always within        ensures that a full panel of specialists is available
31 days from the date of birth or placement for          to provide your health care needs and helps
adoption. The Personal Physician selected for            your Personal Physician manage the utilization
the month of birth must be in the same medical           of your health plan benefits by ensuring that re-

                                                     7
BASIC PLAN
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
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
                                                          IT IS IMPORTANT TO KNOW THAT
Personal Physician and Access+ Specialist visits.
                                                          WHEN YOU ENROLL IN THE BLUE
Once your medical group or IPA change is ef-
                                                          SHIELD ACCESS+ HMO, SERVICES ARE
fective, all previous authorizations for specialty
                                                          PROVIDED THROUGH THE PLAN’S DE-
care or procedures are no longer valid and must
                                                          LIVERY SYSTEM, BUT THE CONTINUED
be transitioned to specialists affiliated with the
                                                          PARTICIPATION OF ANY ONE DOCTOR,
new medical group or IPA, even if you remain
                                                          HOSPITAL OR OTHER PROVIDER CAN-
with the same Personal Physician. Member Ser-
                                                          NOT BE GUARANTEED.
vices will assist you with the timing and choice

                                                      8
BASIC PLAN
Continuity of Care by a Terminated                        spond and warns the Member of the possibility
Provider                                                  of termination.
Members who are being treated for acute condi-
tions, serious chronic conditions, pregnancies            How to Receive Care
(including immediate postpartum care), or ter-            Use of Personal Physician
minal illness; or who are children from birth to          At the time of enrollment, you will choose a
36 months of age; or who have received au-                Personal Physician who will coordinate all cov-
thorization from a now-terminated provider for            ered services. You must contact your Personal
surgery or another procedure as part of a docu-           Physician for all health care needs, including
mented course of treatment can request comple-            preventive services, routine health problems,
tion of care in certain situations with a provider        consultations with Plan specialists (except as
who is leaving the Blue Shield provider network.          provided under Obstetrical/Gynecological
Contact Member Services to receive information            (OB/GYN) Physician Services, Access+ Spe-
regarding eligibility criteria and the policy and         cialist, and Mental Health and Substance Abuse
procedure for requesting continuity of care from          Services), admission into a hospice program
a terminated provider.                                    through a participating hospice agency, emer-
                                                          gency services, urgent services and for hospitali-
Relationship With Your Personal                           zation. The Personal Physician is responsible for
Physician                                                 providing primary care and coordinating or ar-
The physician-patient relationship you and your           ranging for referral to other necessary health
Personal Physician establish is very important.           care services and requesting any needed prior
The best effort of your Personal Physician will           authorization. You should cancel any scheduled
be used to ensure that all medically necessary            appointments at least 24 hours in advance. This
and appropriate professional services are pro-            policy applies to appointments with or arranged
vided to you in a manner compatible with your             by your Personal Physician or the Mental Health
wishes. If your Personal Physician recommends             Services Administrator (MHSA) and self-
procedures or treatments which you refuse, or             arranged appointments to an Access+ Specialist
you and your Personal Physician fail to establish         or for OB/GYN services. Because your physi-
a satisfactory relationship, you may select a dif-        cian has set aside time for your appointments in
ferent Personal Physician. Member Services can            a busy schedule, you need to notify the office
assist you with this selection.                           within 24 hours if you are unable to keep the
                                                          appointment. That will allow the office staff to
Your Personal Physician will advise you if he be-         offer that time slot to another patient who needs
lieves that there is no professionally acceptable         to see the physician. Some offices may advise
alternative to a recommended treatment or pro-            you that a fee (not to exceed your copayment)
cedure. If you continue to refuse to follow the           will be charged for missed appointments unless
recommended treatment or procedure, Member                you give 24-hour advance notice or missed the
Services can assist you in the selection of an-           appointment because of an emergency situation.
other Personal Physician.
                                                          If you have not selected a Personal Physician for
Repeated failures to establish a satisfactory rela-       any reason, you must contact Member Services
tionship with a Personal Physician may result in          at 1-800-334-5847, Monday through Friday, be-
termination of your coverage, but only after you          tween 7 a.m. and 7 p.m. to select a Personal
have been given access to other available Per-            Physician to obtain benefits.
sonal Physicians and have been unsuccessful in
establishing a satisfactory relationship. Any such        Obstetrical/Gynecological (OB/GYN)
termination will take place in accordance with            Physician Services
written procedures established by Blue Shield             A female Member may arrange for obstetrical
and only after written notice to the Member               and/or gynecological (OB/GYN) services by an
which describes the unacceptable conduct, pro-            obstetrician/gynecologist or a family practice
vides the Member with an opportunity to re-               physician who is not her designated Personal

                                                      9
BASIC PLAN
Physician without obtaining a referral. However,           will request any necessary prior authorization
the obstetrician/gynecologist or family practice           from your medical group or IPA. For mental
physician must be in the same medical group or             health care and substance abuse benefits, see the
IPA as 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


                                                      10
BASIC PLAN
Personal Physician. If the Personal Physician de-          the appointment because of an emergency situa-
termines that specialty services are medically             tion, the physician’s office may charge you a fee
necessary, the physician will complete a referral          as much as the Access+ Specialist copayment.
form and request necessary authorization. Your
Personal Physician will designate the Plan pro-            For Access+ Specialist visits for mental health
vider from whom you will receive services.                 and substance abuse services, see the following
When no Plan provider is available to perform              Mental Health and Substance Abuse Services
the needed service, the Personal Physician will            paragraphs.
refer you to a non-Plan provider after obtaining
authorization. This authorization procedure is             The Access+ Specialist visit includes:
handled for you by your Personal Physician.
                                                            • An examination or other consultation
In certain situations where the Member's medi-                provided to you by a medical group Plan
cal condition or disease is life-threatening, de-             specialist without referral from your Per-
generative, or disabling and requires specialized             sonal Physician;
medical care over a prolonged period of time,               • Conventional x-rays such as chest x-rays,
the Personal Physician may make a standing re-                abdominal flat plates, and x-rays of
ferral (more than one visit) to an appropriate                bones to rule out the possibility of frac-
specialist.                                                   ture (but does not include any diagnostic
                                                              imaging such as CT, MRI, or bone den-
Referral by a Personal Physician does not guar-               sity measurement);
antee coverage for referral services. The eligibil-         • Laboratory services;
ity provisions, exclusions and limitations will             • Diagnostic or treatment procedures
apply.                                                        which a Plan specialist would regularly
                                                              provide under a referral from the Per-
Access+ Specialist                                            sonal Physician.
You may arrange an office visit with a Plan spe-
cialist in the same medical group or IPA as your           An Access+ Specialist visit does not include:
Personal Physician without a referral from your
Personal Physician, subject to the limitations de-          • Any services which are not covered or
scribed below. Access+ Specialist office visits               which are not medically necessary;
are available only to Members whose Personal                • Services provided by a non-Access+
Physicians belong to a medical group or IPA                   Provider (such as podiatry and physical
that participates as an Access+ Provider. Refer               therapy), except for the x-ray and labora-
to the HMO Physician and Hospital Directory                   tory services described above;
or call Blue Shield Member Services at 1-800-               • Allergy testing;
334-5847 to determine whether a medical group               • Endoscopic procedures;
or IPA is an Access+ Provider. You will be re-              • Any diagnostic imaging including CT,
sponsible for a $30 copayment for each Access+                MRI, or bone density measurement;
Specialist visit. This copayment is in addition to          • Injectables, chemotherapy or other infu-
any copayments that you may incur for specific                sion drugs, other than vaccines and anti-
benefits as described in the Summary of Bene-                 biotics;
fits. Each follow-up office visit with the Plan             • Infertility services;
specialist which is not referred or authorized by           • Emergency services;
your Personal Physician is a separate Access+
                                                            • Urgent services;
Specialist visit and requires a separate $30 co-
payment.                                                    • Inpatient services, or any services which
                                                              result in a facility charge, except for rou-
You should cancel any scheduled Access+ Spe-                  tine x-ray and laboratory services;
cialist appointment at least 24 hours in advance.           • Services for which the medical group or
Unless you give 24-hour advance notice or miss                IPA routinely allows the Member to self-


                                                      11
BASIC PLAN
   refer without authorization from the                  Non-emergency mental health and substance
   Personal Physician;                                   abuse services received from a provider who
 • OB/GYN services by an obstetrician/                   does not participate in the MHSA Participating
   gynecologist or a family practice physi-              Provider network will not be covered and all
   cian within the same medical group or                 charges for these services will be the Member’s
   IPA as the Personal Physician;                        responsibility.
 • Internet-based consultations.
                                                         For complete information regarding benefits for
Lifepath Advisers                                        mental health and substance abuse services, see
Blue Shield of California's Lifepath Advisers            Q. Inpatient Mental Health and Substance
provides Members with no charge, confidential,           Abuse Services and R. Outpatient Mental
unlimited telephone support for information,             Health and Substance Abuse Services in the
consultations, and referrals for health and psy-         Benefit Descriptions section.
chosocial issues. Members may obtain these ser-
vices by calling 1-866-543-3728, a 24-hour, toll-        1. Prior Authorization
free telephone number. There is no charge for
                                                            All non-emergency mental health and sub-
these services.
                                                            stance abuse services must be prior author-
Lifepath Advisers includes a nurse support (see             ized by the MHSA. For prior authorization
C. Preventive Health Services) and a psychoso-              of mental health and substance abuse ser-
cial support feature (see the following section             vices, the Member should contact the
Mental Health and Substance Abuse Services).                MHSA at 1-866-505-3409.

Mental Health and Substance Abuse                           Failure to receive prior authorization for
                                                            mental health and substance abuse services
Services                                                    as described, except for emergency and ur-
Blue Shield of California has contracted with a             gent services, will result in the Member be-
Mental Health Services Administrator (MHSA)                 ing totally responsible for all costs for these
to underwrite and deliver all mental health and             services.
substance abuse services through a unique net-
work of mental health Participating Providers.              Note: The MHSA will render a decision on
(See Mental Health Services Administrator un-               all requests for prior authorization of ser-
der the Definitions section for more informa-               vices as follows:
tion.) All non-emergency mental health and
substance abuse services, except for Access+                • for urgent services, as soon as possible
Specialist visits, must be arranged through the               to accommodate the Member’s condi-
MHSA. Members do not need to arrange for                      tion not to exceed 72 hours from re-
mental health and substance abuse services                    ceipt of the request;
through their Personal Physician. (See 1. Prior             • for other services, within 5 business
Authorization paragraphs below.)                              days from receipt of the request. The
                                                              treating provider will be notified of the
All mental health and substance abuse services,               decision within 24 hours followed by
except for emergency or urgent services, must                 written notice to the provider and
be provided by a MHSA Participating Provider.                 Member within 2 business days of the
MHSA Participating Providers are indicated in                 decision.
the Blue Shield of California Behavioral Health
Provider Directory. Members may contact the              2. Access+ Specialist Visits for Mental Health
MHSA directly for information on, and to select             and Substance Abuse Services
a MHSA Participating Provider by calling 1-866-
505-3409. Your Personal Physician may also                  The Access+ Specialist feature is available
contact the MHSA to obtain information re-                  for all mental health and substance abuse
garding MHSA Participating Providers for you.               services except for psychological testing and

                                                    12
BASIC PLAN
   written evaluation which are not covered                   be resolved in a brief treatment regimen, the
   under this benefit.                                        Member will be referred to the MHSA in-
                                                              take line to access his mental health and
   The Member may arrange for an Access+                      substance abuse services which are de-
   Specialist office visit for mental health and              scribed under R. Outpatient Mental Health
   substance abuse services without a referral                and Substance Abuse Services.
   from the MHSA, as long as the provider is a
   MHSA Participating Provider. Refer to the               Emergency Services
   Blue Shield of California Behavioral Health             What is an Emergency?
   Provider Directory or call the MHSA at                  An emergency means an unexpected medical
   1-866-505-3409 to determine MHSA Par-                   condition manifesting itself by acute symptoms
   ticipating Providers. Members will be re-               of sufficient severity (including severe pain)
   sponsible for a $30 copayment for each                  such that a layperson who possesses an average
   Access+ Specialist visit for mental health              knowledge of health and medicine could rea-
   and substance abuse services. Each follow-              sonably assume that the absence of immediate
   up office visit for mental health and sub-              medical attention could be expected to result in
   stance abuse services which is not referred             any of the following: (1) placing the Member’s
   or authorized by the MHSA is a separate                 health in serious jeopardy, (2) serious impair-
   Access+ Specialist visit and requires a sepa-           ment to bodily functions, (3) serious dysfunc-
   rate $30 copayment.                                     tion of any bodily organ or part. If you receive
                                                           non-authorized services in a situation that Blue
3. Psychosocial Support                                    Shield determines was not a situation in which a
                                                           reasonable person would believe that an emer-
   Notwithstanding the benefits provided un-
                                                           gency condition existed, you will be responsible
   der R. Outpatient Mental Health and Sub-
                                                           for the costs of those services.
   stance Abuse Services, the Member also
   may call 1-866-543-3728 on an unlimited,                Members who reasonably believe that they have
   24-hour basis for confidential psychosocial             an emergency medical or mental health condi-
   support services available through Lifepath             tion which requires an emergency response are
   Advisers. Professional counselors will pro-             encouraged to appropriately use the “911”
   vide support through assessment, referrals              emergency response system where available.
   and counseling.
                                                           What to do in case of Emergency:
   In California, support may include, as ap-
   propriate, a referral to a counselor for a              Life Threatening
   maximum of three no charge, face-to-face                   Obtain care immediately.
   visits per episode of major life events. An
   episode shall mean a single event, or multi-               Contact your Personal Physician no later
   ple events which occur within a 6-month                    than 24 hours after the onset of the emer-
   period and are determined by a counselor to                gency.
   be related. Major life events include work-
   related problems, marital and relationship              Non-Life Threatening
   issues, family problems, emotional and per-                Consult your Personal Physician, anytime
   sonal issues and death and dying issues.                   day or night, regardless of where you are
   These visits will not accrue to the benefit                prior to receiving medical care.
   maximums that are applicable to mental
   health and substance abuse services.                    Follow-Up Care
                                                              Follow-up care, which is any care provided
   In the event that the services required of a               after the initial emergency room visit, must
   Member are most appropriately provided by                  be provided or authorized by your Personal
   a psychiatrist or the condition is not likely to           Physician.


                                                      13
BASIC PLAN
For a complete description of the Emergency                If services are not received from a BlueCard
Services benefit and applicable copayments, see            Program participating provider, you may be re-
I. Emergency Services in the Benefit Descrip-              quired to pay the provider for the entire cost of
tions section.                                             the service and submit a claim to the Blue Shield
                                                           Access+ HMO. Claims for urgent services and
Urgent Services                                            out-of-area follow-up care rendered outside of
The Blue Shield Access+ HMO provides cover-                California and not provided by a BlueCard Pro-
age for you and your family for your urgent ser-           gram participating provider will be reviewed ret-
vice needs when you or your family are                     rospectively for coverage.
temporarily traveling outside of your Personal
Physician service area.                                    Under the BlueCard Program, when you obtain
                                                           health care services outside of California, the
Urgent services are defined in Section 3, under            amount you pay, if not subject to a flat dollar
Definitions. Out-of-area follow-up care is de-             copayment, is calculated on the lower of:
fined in Section 3, under Definitions.
                                                           1. The billed charges for your covered services,
Outside of California or the United States                    or
The Blue Shield Access+ HMO provides cover-
age for you and your family for your urgent ser-           2. The negotiated price that the local Blue
vice needs when you or your family are                        Cross and/or Blue Shield plan passes on to
temporarily traveling outside of California. You              us.
can receive urgent care services from any pro-
vider; however, using the BlueCard® Program,               Often, this "negotiated price" will consist of a
described below, can be more cost-effective and            simple discount which reflects the actual price
eliminate the need for you to pay for the services         paid by the local Blue Cross and/or Blue Shield
when they are rendered and submit a claim for re-          plan. But sometimes it is an estimated price that
imbursement.                                               factors into the actual price expected settle-
                                                           ments, withholds, any other contingent payment
Through the BlueCard Program, you can access               arrangements and non-claims transactions with
urgent care services across the country and                your health care provider or with a specified
around the world. While traveling within the               group of providers. The negotiated price may
United States, you can locate a BlueCard Pro-              also be billed charges reduced to reflect an aver-
gram participating provider any time by calling            age expected savings with your health care pro-
1-800-810-BLUE (2583) or going on-line at                  vider or with a specified group of providers.
www.bcbs.com and selecting the “Find a Doc-                The price that reflects average savings may re-
tor or Hospital” tab. If you are traveling outside         sult in greater variation (more or less) from the
of the United States, you can call 1-804-673-1177          actual price paid than will the estimated price.
collect 24 hours a day to locate a BlueCard                The negotiated price will also be adjusted in the
Worldwide® Network provider.                               future to correct for over- or underestimation of
                                                           past prices. However, the amount you pay is
Out-of-area follow-up care is covered and may              considered a final price.
be received through the BlueCard Program par-
ticipating provider network or from any pro-               Statutes in a small number of states may require
vider. However, authorization by Blue Shield is            the local Blue Cross and/or Blue Shield plan to
required for more than two out-of-area follow-             use a basis for calculating Member liability for
up care outpatient visits or for care that involves        covered services that does not reflect the entire
a surgical or other procedure or inpatient stay.           savings realized, or expected to be realized, on a
The Blue Shield Access+ HMO may direct the                 particular claim or to add a surcharge. Should
patient to receive the additional follow-up ser-           any state statutes mandate Member liability cal-
vices from the Personal Physician.                         culation methods that differ from the usual
                                                           BlueCard Program method noted above or re-


                                                      14
BASIC PLAN
quire a surcharge, Blue Shield of California                California, the amount you pay, if not subject to
would then calculate your liability for any cov-            a flat dollar copayment, is calculated on Blue
ered health care services in accordance with the            Shield’s allowed charges.
applicable state statute in effect at the time you
received your care.                                         See J. Urgent Services in the Benefit Descrip-
                                                            tions section for benefit description, applicable
For any other providers, the amount you pay, if             copayment information, and information on
not subject to a flat dollar copayment, is calcu-           payment responsibility and claims submission.
lated on the provider’s billed charges for your
covered services.                                           Inpatient, Home Health Care
                                                            and Other Services
Within California                                           The Personal Physician is responsible for ob-
If you are temporarily traveling within Califor-            taining prior authorization before you can be
nia, but are outside of your Personal Physician             admitted to the hospital or a skilled nursing fa-
service area, if possible you should call Blue              cility, including subacute care admissions, except
Shield Member Services at 1-800-334-5847 for                for mental health and substance abuse services
assistance in receiving urgent services through a           which are described in the previous Mental
Blue Shield of California Plan provider. You may            Health and Substance Abuse Services section.
also locate a Plan provider by visiting our web site        The Personal Physician is responsible for ob-
at http://www.blueshieldca.com. However, you                taining prior authorization before you can re-
are not required to use a Blue Shield of California         ceive home health care and certain other
Plan provider to receive urgent services; you may           services or before you can be admitted into a
use any provider. Remember that when you are                hospice program through a participating hospice
within your Personal Physician service area, ur-            agency. If the Personal Physician determines
gent services must be provided or authorized by             that you should receive any of these services, he
your Personal Physician just like all other non-            or she will request authorization. Your Personal
emergency services of the Plan.                             Physician will arrange for your admission to the
                                                            hospital, skilled nursing facility, or a hospice
Follow-up care is also covered through a Blue               program through a participating hospice agency,
Shield of California Plan provider and may also             as well as for the provision of home health care
be received from any provider. However, when                and other services.
outside your Personal Physician service area au-
thorization by Blue Shield is required for more             For hospital admissions for mastectomies or
than two out-of-area follow-up care outpatient              lymph node dissections, the length of hospital
visits or for care that involves a surgical or other        stays will be determined solely by the Member’s
procedure or inpatient stay. The Blue Shield Ac-            physician in consultation with the Member. For
cess+ HMO may direct the patient to receive the             information regarding length of stay for mater-
additional follow-up services from the Personal             nity or maternity-related services, see F. Preg-
Physician.                                                  nancy and Maternity Care, for information
                                                            relative to the Newborns’ and Mothers’ Health
If services are not received from a Blue Shield             Protection Act.
of California Plan provider, you may be required
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-
side your Personal Physician service area within


                                                       15
BASIC PLAN
Copayments for the following services do not              cian/gynecologist or a family practice physician
apply towards the Member maximum calendar                 who is in the same medical group or IPA as the
year copayment responsibility:                            Personal Physician, and all mental health and
                                                          substance abuse services, must have prior au-
1. Access+ Specialist office visits including vis-        thorization by the Personal Physician, medical
   its for mental heath and substance abuse;              group or IPA. The Member will be responsible
                                                          for payment of services that are not authorized
2. Infertility services;                                  or those that are not an emergency or covered
                                                          out of service area urgent service procedures.
3. Outpatient prescription drugs.                         (See the previous Urgent Services paragraphs
                                                          for information on receiving urgent services out
Charges for services not covered and services             of the service area but within California.) Mem-
not prior approved by the Personal Physician,             bers must obtain services from the Plan provid-
except those meeting the emergency and urgent             ers that are authorized by their Personal
care requirements, are your responsibility, do            Physician, medical group or IPA and, for all
not apply towards the Member maximum calen-               mental health and substance abuse services,
dar year copayment responsibility, and may                from MHSA Participating Providers. Hospice
cause your payment responsibility to exceed the           services must be received from a participating
Member maximum calendar year copayment re-                hospice agency.
sponsibility defined above.
                                                          If your condition requires services which are
Note that copayments and charges for services             available from the Plan, payment for services
not accruing to the Member maximum calendar               rendered by non-Plan providers will not be con-
year copayment continue to be the Member's re-            sidered unless the medical condition requires
sponsibility after the calendar year copayment            emergency or urgent services.
maximum is reached.
                                                          You are responsible for paying a minimum
Note: It is your responsibility to maintain accu-         charge (copayment) to the physician or provider
rate records of your copayments and to deter-             of services at the time you receive services. The
mine and notify Blue Shield when the Member               specific copayments, as applicable, are listed af-
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

                                                     16
BASIC PLAN
Shield Member Services Department so that                                        1-877-263-9952
they can coordinate your care and direct your
                                                                U.S. Behavioral Health Plan, California
Personal Physician or pharmacy.
                                                                3111 Camino Del Rio North, Suite 600
                                                                        San Diego, CA 92108
Member Services Department
For all services other than mental health and             The MHSA can answer many questions over the
substance abuse                                           telephone.
If you have a question about services, providers,
benefits, how to use this plan, or concerns re-           The MHSA has established a procedure for our
garding the quality of care or access to care that        Members to request an expedited decision. A
you have experienced, you should call the Blue            Member, physician, or representative of a Mem-
Shield Member Services Department at 1-800-               ber may request an expedited decision when the
334-5847. The hearing impaired may contact                routine decision making process might seriously
Blue Shield’s Member Services Department                  jeopardize the life or health of a Member, or
through Blue Shield’s toll-free TTY number,               when the Member is experiencing severe pain.
1-800-241-1823. Member Services can answer                The MHSA shall make a decision and notify the
many questions over the telephone.                        Member and physician as soon as possible to
                                                          accommodate the Member’s condition not to
Expedited Decision                                        exceed 72 hours following the receipt of the re-
Blue Shield of California has established a pro-          quest. An expedited decision may involve ad-
cedure for our Members to request an expedited            missions, continued stay or other health care
decision (including those regarding grievances).          services. If you would like additional informa-
A Member, physician, or representative of a               tion regarding the expedited decision process, or
Member may request an expedited decision                  if you believe your particular situation qualifies
when the routine decision making process might            for an expedited decision, please contact the
seriously jeopardize the life or health of a Mem-         MHSA at the number listed above.
ber, or when the Member is experiencing severe
pain. Blue Shield shall make a decision and no-           For information on additional rights, see the
tify the Member and physician as soon as possi-           Grievance Process section.
ble to accommodate the Member’s condition
not to exceed 72 hours following the receipt of           Rates for Basic Plan
the request. An expedited decision may involve            State Employees and Annuitants
admissions, continued stay or other health care           The rates shown below are effective January 1,
services. If you would like additional informa-           2008, and will be reduced by the amount the
tion regarding the expedited decision process, or         State of California contributes toward the cost
if you believe your particular situation qualifies        of your health benefit plan. These contribution
for an expedited decision, please contact our             amounts are subject to change as a result of col-
Member Services Department at 1-800-334-                  lective bargaining agreements or legislative ac-
5847.                                                     tion. Any such change will be accomplished by
                                                          the State Controller or affected retirement sys-
For all mental health and substance abuse                 tem without any action on your part. For cur-
services                                                  rent contribution information, contact your
For all mental health and substance abuse ser-            employing agency or retirement system health
vices Blue Shield of California has contracted            benefits officer.
with the Plan’s Mental Health Services Adminis-
trator (MHSA). The MHSA should be contacted               Cost of the Program
for questions about mental health and substance           Type of Enrollment                                Monthly Rate
abuse services, MHSA Participating Providers,
                                                          Employee only................................................ $479.47
or mental health and substance abuse benefits.
You may contact the MHSA at the telephone                 Employee and one dependent ..................... $958.94
number or address which appear below:                     Employee and two or more dependents .. $1246.62

                                                     17
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/Sacramento Counties
gion in which the employee/annuitant resides.
See below a description of the pricing regions. If                            2   Other Northern California Counties
the employee/annuitant lives outside of the
Plan’s service area and is enrolled based on                                  3   Los Angeles/Ventura/San Bernardino Coun-
place of employment, then the pricing region                                      ties
for the place of employment will apply. If the
employee/annuitant moves from one pricing                                     4   Other Southern California Counties
region to another, rates will change on the first
of the month following the change of residence.                               Rate Change
The rates shown below are effective January 1,                                The plan rates may be changed as of January 1,
2008, and will be reduced by the amount your                                  2009, following at least 60 days’ written notice
contracting agency contributes toward the cost                                to the Board prior to such change.
of your health benefit plan. This amount varies
among public agencies. For assistance on calcu-
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 ................................................... $532.93
  Region 2 ................................................... $540.94
  Region 3 ................................................... $392.01
  Region 4 ................................................... $447.97
Employee and one dependent
  Region 1 .................................................$1065.86
  Region 2 .................................................$1081.88
  Region 3 ................................................... $784.02
  Region 4 ................................................... $895.94
Employee and two or more dependents
  Region 1 .................................................$1385.62
  Region 2 .................................................$1406.44
  Region 3 .................................................$1019.23
  Region 4 .................................................$1164.72




                                                                         18
BASIC PLAN
Benefit Descriptions                                     g. Drugs, medications, biologicals, and
The Plan benefits available to you are listed in            oxygen administered in the hospital, and
this section. The copayments for these services,            up to 3 days’ supply of drugs supplied
if applicable, follow each benefit description.             upon discharge by the Plan physician for
                                                            the purpose of transition from the hospi-
The following are the basic health care services            tal to home;
covered by the Blue Shield Access+ HMO
without charge to the Member, except for co-             h. Surgical and anesthetic supplies, dress-
payments where noted, and as set forth in the               ings and cast materials, surgically im-
Third Party Recovery Process and the Member’s               planted devices and prostheses, other
Responsibility section. These services are cov-             medical supplies and medical appliances
ered when medically necessary, and when pro-                and equipment administered in hospital;
vided by the Member’s Personal Physician or
                                                         i. Processing, storage and administration of
other Plan provider or authorized as described
                                                            blood, and blood products (plasma), in
herein, or received according to the provisions
                                                            inpatient and outpatient settings. In-
described under Obstetrical/Gynecological
                                                            cludes the storage and collection of
(OB/GYN) Physician Services, Access+ Spe-
                                                            autologous blood;
cialist, and Mental Health and Substance Abuse
Services. Coverage for these services is subject         j. Radiation therapy, chemotherapy and re-
to all terms, conditions, limitations and exclu-            nal dialysis;
sions of the Agreement, to any conditions or
limitations set forth in the benefit descriptions        k. Respiratory therapy and other diagnostic,
below, and to the Exclusions and Limitations                therapeutic and rehabilitation services as
set forth in this booklet.                                  appropriate;

A. Hospital Services                                     l. Coordinated discharge planning, includ-
The following hospital services customarily fur-            ing the planning of such continuing care
nished by a hospital will be covered when medi-             as may be necessary;
cally necessary and authorized.                          m. Inpatient services, including general an-
                                                            esthesia and associated facility charges, in
1. Inpatient hospital services include:
                                                            connection with dental procedures when
    a. Semi-private room and board, unless a                hospitalization is required because of an
       private room is medically necessary;                 underlying medical condition and clinical
                                                            status or because of the severity of the
    b. General nursing care, and special duty               dental procedure. Includes enrollees un-
       nursing when medically necessary;                    der the age of 7 and the developmentally
                                                            disabled who meet these criteria. Ex-
    c. Meals and special diets when medically               cludes services of dentist or oral surgeon;
       necessary;
                                                         n. Subacute care;
    d. Intensive care services and units;
                                                         o. Medically necessary inpatient substance
    e. Operating room, special treatment                    abuse detoxification services required to
       rooms, delivery room, newborn nursery                treat potentially life-threatening symp-
       and related facilities;                              toms of acute toxicity or acute with-
                                                            drawal are covered when a covered
    f. Hospital ancillary services including di-            Member is admitted through the emer-
       agnostic laboratory, x-ray services and              gency room or when medically necessary
       therapy services;                                    inpatient substance abuse detoxification
                                                            is prior authorized;


                                                    19
BASIC PLAN
    p. Rehabilitation when furnished by the                        medications administered in the phy-
       hospital and authorized.                                    sician’s office, including chemother-
                                                                   apy.
See Section O. for inpatient hospital services
provided under the “Hospice Program Services”               2. Allergy Testing and Treatment
benefit.
                                                               Office visits for the purpose of allergy test-
        Copayment: No charge.                                  ing and treatment, including injectables and
                                                               serum.
2. Outpatient hospital services include:
                                                                   Copayment: No charge.
    a. Services and supplies for treatment or
       surgery in an outpatient hospital setting            3. Inpatient Medical and Surgical Services
       or ambulatory surgery center;
                                                               Physicians’ services in a hospital or skilled
    b. Outpatient services, including general                  nursing facility for examination, diagnosis,
       anesthesia and associated facility charges,             treatment, and consultation, including the
       in connection with dental procedures                    services of a surgeon, assistant surgeon, an-
       when the use of a hospital or outpatient                esthesiologist, pathologist, and radiologist.
       facility is required because of an underly-             Inpatient physician services are covered only
       ing medical condition and clinical status               when hospital and skilled nursing facility
       or because of the severity of the dental                services are also covered.
       procedure. Includes enrollees under the
       age of 7 and the developmentally dis-                       Copayment: No charge.
       abled who meet these criteria. Excludes
       services of dentist or oral surgeon.                 4. Medically necessary home visits by Plan
                                                               physician
        Copayment: No charge.
                                                                   Copayment: $15 per visit.
B. Physician Services (Other Than for
   Mental Health and Substance Abuse                        5. Treatment of physical complications of a
   Services)                                                   mastectomy, including lymphedemas
1. Physician Office Visits
                                                                   Copayment: $15 per visit.
    Office visits for examination, diagnosis and
    treatment of a medical condition, disease or            6. Internet-Based Consultations. Medically
    injury, including specialist office visits, sec-           necessary consultations with Internet Ready
    ond opinion or other consultations, diabetic               Physicians via Blue Shield approved Internet
    counseling, and OB/GYN services from an                    portal. Internet-based consultations are
    obstetrician/gynecologist or a family prac-                available only to Members whose Personal
    tice physician who is within the same medi-                Physicians (or other physicians to whom
    cal group or IPA as the Personal Physician.                you have been referred for care within your
    Benefits are also provided for asthma self-                Personal Physician’s medical group or IPA)
    management training and education to en-                   have agreed to provide Internet-based con-
    able a Member to properly use asthma-                      sultations via the Blue Shield approved
    related medication and equipment such as                   Internet portal (“Internet Ready”). Internet-
    inhalers, spacers, nebulizers and peak flow                based consultations for mental health and
    monitors.                                                  substance abuse care are not covered. Refer
                                                               to the On-Line Physician Directory to de-
        Copayment: $15 per visit. No addi-                     termine whether your physician is Internet
        tional charge for surgery or anesthesia;               Ready and how to initiate an Internet-based
        radiation or renal dialysis treatments;

                                                       20
BASIC PLAN
    consultation. This information can be ac-                b. Periodic health examinations for adults.
    cessed at http://www.blueshieldca.com.                      Includes all routine diagnostic testing
                                                                and laboratory services appropriate for
        Copayment: $10 per consultation.                        such examinations as recommended by
                                                                the most recent version with all updates
C. Preventive Health Services                                   of the Guide to Preventive Services of the
Preventive care services are those primary pre-                 U.S. Preventive Services Task Force as
ventive medical services provided by a physician                convened by the U.S. Public Health Ser-
for the early detection of disease when no symp-                vice. Includes coverage for the screening
toms are present and for those items specifically               and diagnosis of prostate cancer, includ-
listed below.                                                   ing, but not limited to, prostate-specific
                                                                antigen testing and digital rectal examina-
1. Scheduled routine physical examinations as                   tions, when medically necessary and con-
   follows:                                                     sistent with good medical practice.

    • Well baby care through age 2 years;                 2. Immunizations. Immunizations for children
    • Exams every year, age 3-19 years;                      through the age of 18 and adults as recom-
    • Exams every 5 years, age 20-40 years;                  mended by the Centers for Disease Control
    • Exams every 2 years, age 41-50 years;                  and Prevention’s Advisory Committee on
    • Exams every year over age 50 years;                    Immunization Practices (ACIP) and ac-
    • Routine breast and pelvic exams and                    cepted by the American College of Obste-
      Pap tests or other Food and Drug                       tricians and Gynecologists, the American
      Administration (FDA) approved cer-                     Academy of Family Physicians, and the
      vical cancer and human papillomavirus                  American Academy of Pediatrics. Includes
      virus (HPV) screening tests every year.                immunizations required for travel and im-
      A woman may self-refer to an obste-                    munizations, such as Hepatitis B, for indi-
      trician/gynecologist or a family prac-                 viduals at occupational risk.
      tice physician who is in the same
                                                          3. Vision screening by the Personal Physician
      medical group or IPA as her Personal
                                                             for Members to determine the need for a re-
      Physician for a routine annual gyneco-
                                                             fraction for vision correction.
      logical exam;
    • Mammography for screening purposes                  4. Hearing screening by the Personal Physician
      as recommended by Member’s Per-                        for Members to determine the need for an
      sonal Physician;                                       audiogram for hearing correction, as well as
    • Annual gynecological exam - annual                     newborn hearing screening services.
      routine examination by an obstetri-
      cian/gynecologist without a referral                5. Eye refraction to determine the need for
      from the Member’s Personal Physi-                      corrective lenses for all Members upon re-
      cian, as long as the obstetri-                         ferral by the Personal Physician.
      cian/gynecologist is in the same
      medical group or IPA as her Personal                       (Limited to one visit per calendar year, for Mem-
      Physician.                                                 bers aged 18 and over. No limit on number of
                                                                 visits for Members under age 18.)
    a. Periodic health examinations for chil-
       dren. Includes all routine diagnostic test-        6. Nurse support: As part of Lifepath Advis-
       ing and laboratory services appropriate               ers, Members may call a registered nurse via
       for such examinations through the age of              1-866-543-3728, a 24-hour, toll-free number
       18 consistent with the most recent ver-               to receive confidential advice and informa-
       sion of the Recommendations for Pre-                  tion about minor illnesses and injuries,
       ventive Pediatric Health Care, as adopted
       by the American Academy of Pediatrics.

                                                     21
BASIC PLAN
    chronic conditions, fitness, nutrition and              items equally appropriate for a condition, bene-
    other health-related topics.                            fits will be based on the most cost-effective
                                                            item.
        Copayment: No charge.
                                                            1. Durable Medical Equipment
See Section D. for information on coverage of
genetic testing and diagnostic procedures.                     a. Replacement of durable medical equip-
                                                                  ment is covered only when it no longer
D. Diagnostic X-ray/Lab Services                                  meets the clinical needs of the patient or
1. X-ray, Laboratory, Major Diagnostic Ser-                       has exceeded the expected lifetime of the
   vices. All outpatient diagnostic x-ray and                     item.*
   clinical laboratory tests and services, includ-
   ing diagnostic imaging, electrocardiograms,                     *This does not apply to the medically
   diagnostic clinical isotope services, bone                      necessary replacement of nebulizers, face
   mass measurements, and periodic blood                           masks and tubing, and peak flow moni-
   lipid screening.                                                tors for the management and treatment
                                                                   of asthma. (See Section P. for benefits
2. Genetic Testing and Diagnostic Procedures.                      for asthma inhalers and inhaler spacers.)
   Genetic testing for certain conditions when
   the Member has risk factors such as family                  b. Medically necessary repairs and mainte-
   history or specific symptoms. The testing                      nance of durable medical equipment, as
   must be expected to lead to increased or al-                   authorized by Plan provider. Repair is
   tered monitoring for early detection of dis-                   covered unless necessitated by misuse or
   ease, a treatment plan or other therapeutic                    loss.
   intervention and determined to be medically                 c. Rental charges for durable medical
   necessary and appropriate in accordance                        equipment in excess of the purchase
   with Blue Shield of California medical pol-                    price are not covered.
   icy.
                                                               d. Benefits do not include environmental
See Section F. for genetic testing for prenatal di-               control equipment or generators. No
agnosis of genetic disorders of the fetus.                        benefits are provided for backup or al-
                                                                  ternate items.
        Copayment: No charge.
                                                            See Section V. for devices, equipment and sup-
E. Durable Medical Equipment,                               plies for the management and treatment of dia-
   Prostheses and Orthoses and                              betes.
   Other Services
Medically necessary durable medical equipment,              If you are enrolled in a hospice program
prostheses and orthoses for activities of daily             through a participating hospice agency, medical
living, and supplies needed to operate durable              equipment and supplies that are reasonable and
medical equipment; oxygen and oxygen equip-                 necessary for the palliation and management of
ment and its administration; blood glucose                  terminal illness and related conditions are pro-
monitors as medically appropriate for insulin               vided by the hospice agency. For information
dependent, non-insulin dependent and gesta-                 see Section O.
tional diabetes; apnea monitors; and ostomy and
medical supplies to support and maintain gastro-            2. Prostheses
intestinal, bladder or respiratory function are
covered. Benefits are provided at the most cost-               a. Medically necessary prostheses for activi-
effective level of care that is consistent with pro-              ties of daily living, including the follow-
fessionally recognized standard of practice. If                   ing:
there are two or more professionally recognized

                                                       22
BASIC PLAN
    1) Supplies necessary for the operation            3. Orthoses
       of prostheses;
                                                          a. Medically necessary orthoses for activi-
    2) Initial fitting and replacement after                 ties of daily living, including the follow-
       the expected life of the item;                        ing:
    3) Repairs, even if due to damage;                       1) Special footwear required for foot
                                                                disfigurement which includes but is
    4) Blom-Singer and artificial larynx pros-                  not limited to foot disfigurement
       theses for speech following a laryn-                     from cerebral palsy, arthritis, polio,
       gectomy;                                                 spina bifida, diabetes or by accident
    5) Prosthetic devices used to restore a                     or developmental disability;
       method of speaking following laryn-                   2) Medically necessary functional foot
       gectomy, including initial and subse-                    orthoses that are custom made rigid
       quent prosthetic devices and                             inserts for shoes, ordered by a physi-
       installation accessories. This does not                  cian or podiatrist, and used to treat
       include electronic voice producing                       mechanical problems of the foot, an-
       machines;                                                kle or leg by preventing abnormal
    6) Cochlear implants;                                       motion and positioning when im-
                                                                provement has not occurred with a
    7) Contact lenses if medically necessary                    trial of strapping or an over-the-
       to treat eye conditions such as kerato-                  counter stabilizing device;
       conus, keratitis sicca or aphakia. Cata-
       ract spectacles or intraocular lenses                 3) Medically necessary knee braces for
       that replace the natural lens of the eye                 post-operative rehabilitation follow-
       after cataract surgery. If medically                     ing ligament surgery, instability due to
       necessary with the insertion of the in-                  injury, and to reduce pain and insta-
       traocular lens, one pair of conven-                      bility for patients with osteoarthritis.
       tional eyeglasses or contact lenses;               b. Benefits for medically necessary orthoses
    8) Artificial limbs and eyes.                            are provided at the most cost-effective
                                                             level of care that is consistent with pro-
 b. Routine maintenance is not covered.                      fessionally recognized standards of prac-
                                                             tice. If there are two or more
 c. Benefits do not include wigs for any rea-                professionally recognized appliances
    son, self-help/educational devices or any                equally appropriate for a condition, the
    type of speech or language assistance de-                Plan will provide benefits based on the
    vices, except as specifically provided                   most cost-effective appliance. Routine
    above. See the Exclusions and Limita-                    maintenance is not covered. No benefits
    tions section for a listing of excluded                  are provided for backup or alternate
    speech and language assistance devices.                  items.
    No benefits are provided for backup or
    alternate items.                                      c. Benefits are provided for orthotic de-
                                                             vices for maintaining normal activities of
 For surgically implanted and other pros-                    daily living only. No benefits are pro-
 thetic devices (including prosthetic bras)                  vided for orthotic devices such as knee
 provided to restore and achieve symmetry                    braces intended to provide additional
 incident to a mastectomy, see Section W.                    support for recreational or sports activi-
 Blom-Singer and artificial larynx prostheses                ties or for orthopedic shoes and other
 for speech following a laryngectomy are                     supportive devices for the feet.
 covered as a surgical professional benefit.
                                                              Copayment: No charge.

                                                  23
BASIC PLAN
See Section V. for devices, equipment and sup-            health care provider whose scope of practice in-
plies for the management and treatment of dia-            cludes postpartum and newborn care. The treat-
betes.                                                    ing physician, in consultation with the mother,
                                                          shall determine whether this visit shall occur at
F. Pregnancy and Maternity Care                           home, the contracted facility, or the physician’s
The following pregnancy and maternity care is             office.
covered subject to the General Exclusions and
Limitations.                                              G. Family Planning and Infertility Services
                                                          1. Family Planning Counseling
1. Prenatal and Postnatal Physician Office Vis-
   its                                                            Copayment: No charge.

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

3. Includes providing coverage for all testing                    Copayment: See applicable copay-
   recommended by the California Newborn                          ments for Physician Services and Hos-
   Screening Program and for participating in                     pital Services.
   the statewide prenatal testing program, ad-
   ministered by the State Department of                  4. Elective Abortion
   Health Services, known as the Expanded
   Alpha Feto Protein Program.                                    Copayment: See applicable copay-
                                                                  ments for Physician Services and Hos-
        Copayment: No charge.                                     pital Services.

The Newborns' and Mothers' Health Protection              5. Contraceptive Devices and Fitting
Act requires group health plans to provide a
minimum hospital stay for the mother and new-                     Copayment: $15 per visit; $5 per device
                                                                  in conjunction with office visit. Dia-
born child of 48 hours after a normal, vaginal
                                                                  phragms also covered under Section
delivery and 96 hours after a C-section unless
                                                                  P.; see applicable copayments for Pre-
the attending physician, in consultation with the                 scription Drugs.
mother, determines a shorter hospital length of
stay is adequate.                                         6. Oral, Transdermal Patch, and Vaginal Ring
                                                             Contraceptives
If the hospital stay is less than 48 hours after a
normal, vaginal delivery or less than 96 hours af-                Copayment: See applicable copay-
ter a C-section, a follow-up visit for the mother                 ments for Prescription Drugs.
and newborn within 48 hours of discharge is
covered when prescribed by the treating physi-
cian. This visit shall be provided by a licensed

                                                     24
BASIC PLAN
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            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/                      Copayment: $50 per visit in the hospi-
   admission and the use of the ambulance is                    tal emergency room. (Emergency ser-
   authorized.                                                  vices copayment is waived if Member
                                                                is admitted directly to hospital as an
       Copayment: No charge.                                    inpatient from emergency room or
                                                                kept for observation and hospital bills
I. Emergency Services                                           for an emergency room observation
An emergency means an unexpected medical                        visit.)
condition manifesting itself by acute symptoms
of sufficient severity (including severe pain)           4. Continuing or Follow-up Treatment. The
such that a layperson who possesses an average              Plan will provide benefits for care in a non-
knowledge of health and medicine could rea-                 Plan hospital only for as long as the Mem-
sonably assume that the absence of immediate                ber’s medical condition prevents transfer to
medical attention could be expected to result in            a Plan hospital in the Personal Physician
any of the following: (1) placing the Member’s              service area, as approved by the medical
health in serious jeopardy, (2) serious impair-             group or IPA or by Blue Shield. Unauthor-
ment to bodily functions, (3) serious dysfunc-              ized continuing or follow-up care after the
tion of any bodily organ or part. If you receive            initial emergency has been treated in a non-
services in a situation that the Blue Shield Ac-            Plan hospital, or by a non-Plan provider is
cess+ HMO determines was not a situation in                 not a covered service.
which a reasonable person would believe that an
emergency condition existed, you will be re-             5. Claims for Emergency and Out-of-Area Ur-
sponsible for the costs of those services.                  gent Services. Contact Member Services to
                                                            obtain a claim form.
1. Members who reasonably believe that they
   have an emergency medical or mental health

                                                    25
BASIC PLAN
 a. Emergency. If emergency services were                      nation. The Plan will notify the Member
    received and expenses were incurred by                     of its determination within 30 days from
    the Member, for services other than                        receipt of the claim.
    medical transportation, the Member
    must submit a complete claim with the               J. Urgent Services
    emergency service record for payment to             Urgent services are provided in response to the
    the Plan, within 1 year after the first pro-        patient’s need for a prompt diagnostic workup
    vision of emergency services for which              and/or treatment.
    payment is requested. If the claim is not
    submitted within this period, the Plan              These services are applicable for a medical or
    will not pay for those emergency ser-               mental disorder that: (1) could become an
    vices, unless the claim was submitted as            emergency if not diagnosed and/or treated in a
    soon as reasonably possible as deter-               timely manner, (2) is likely to result in prolonged
    mined by the Plan. If the services are not          temporary impairment, (3) could increase the
    pre-authorized, the Plan will review the            risk of necessitating more complex or hazardous
    claim retrospectively for coverage. If the          treatment, and (4) could develop in a chronic
    Plan determines that these services re-             illness or inordinate physical or psychological
    ceived were for a medical condition for             suffering of the patient.
    which a reasonable person would not
    reasonably believe that an emergency                1. When within California, but outside of your
    condition existed and would not other-                 Personal Physician service area, if possible
    wise have been authorized, and, there-                 contact Blue Shield Member Services at
    fore, are not covered, it will notify the              1-800-334-5847 for assistance in receiving
    Member of that determination. The Plan                 urgent services. Member Services will assist
    will notify the Member of its determina-               Members in receiving urgent services
    tion within 30 days from receipt of the                through a Blue Shield of California Plan
    claim. In the event covered medical                    provider. Members may also locate a Plan
    transportation services are obtained in                provider by visiting Blue Shield’s internet site
    such an emergency situation, the Blue                  at http://www.blueshieldca.com. You are
    Shield Access+ HMO shall pay the                       not required to use a Blue Shield of Califor-
    medical transportation provider directly.              nia Plan provider to receive urgent services;
                                                           you may use any provider. However, the
 b. Out-of-Area Urgent Services. If out-of-                services will be reviewed retrospectively by
    area urgent services were received from a              the Plan to determine whether the services
    non-participating BlueCard Program                     were urgent services.
    provider, you must submit a complete
    claim with the urgent service record for            2. When temporarily traveling within the
    payment to the Plan, within 1 year after               United States, call the 24-hour toll-free
    the first provision of urgent services for             number 1-800-810-BLUE (2583) to obtain
    which payment is requested. If the claim               information about the nearest BlueCard
    is not submitted within this period, the               Program participating provider. When a
    Plan will not pay for those urgent ser-                BlueCard Program participating provider is
    vices, unless the claim was submitted as               available, you should obtain out-of-area ur-
    soon as reasonably possible as deter-                  gent or follow-up care from a participating
    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


                                                   26
BASIC PLAN
   whether the services were urgent services.            K. Home Health Care Services,
   See Section I.5. Claims for Emergency and                PKU-Related Formulas and
   Out-of-Area Urgent Services for additional               Special Food Products, and
   information.                                             Home Infusion Therapy
                                                         1. Home Health Care Services
   Up to two medically necessary out-of-area
   follow-up care outpatient visits are covered.            The following Home Health Care services
   Authorization by Blue Shield is required for             will be covered when the patient is required
   more than two follow-up outpatient visits or             to be at home for medically necessary pur-
   for care that involves a surgical or other               poses at the direction of the Personal Physi-
   procedure or inpatient stay. Blue Shield may             cian and authorized.
   direct the Member to receive the additional
   follow-up care from the Personal Physician.              a. Home visits to provide skilled nursing
                                                               services and other skilled services by any
3. When outside the United States, Members                     of the following professional providers
   may call the BlueCard Worldwide Network                     are covered:
   at 1-804-673-1177. Urgent services are avail-
   able through the BlueCard Worldwide Net-                    1) Registered nurse;
   work, but may be received from any
   provider.                                                   2) Licensed vocational nurse;

   Before traveling abroad, Members should                     3) Certified home health aide in con-
   call their local Member Services office for                    junction with the services of 1) or 2),
   the most current listing of participating pro-                 above;
   viders worldwide or they can go on-line at
                                                                Copayment: No charge.
   www.bcbs.com and select the “Find a Doc-
   tor or Hospital” tab. However, a Member is                  4) Physical     therapist,   occupational
   not required to receive urgent services out-                   therapist, or speech therapist.
   side of the United States from the BlueCard
   Worldwide Network. If the Member does                        Copayment: $15 per visit for therapy
   not use the BlueCard Worldwide Network, a                    provided in the home.
   claim must be submitted as described in
   Section I.5. Claims for Emergency and Out-               b. Medical Social Worker. Medical social
   of-Area Urgent Services.                                    services provided by a licensed medical
                                                               social worker for consultation and
4. Remember that when you are within your                      evaluation.
   Personal Physician service area, urgent ser-
   vices must be provided or authorized by                      Copayment: No charge.
   your Personal Physician just like all other
   non-emergency services of the Plan. When-                c. In conjunction with the professional ser-
   ever possible, you should contact your Per-                 vices rendered by a home health agency,
   sonal Physician. Urgent services required                   medications, drugs and medical supplies
   when the Member is within the Plan service                  used during a covered visit by the home
   area, but not within your own service area,                 health agency necessary for the home
   must be obtained in accordance with all the                 health care treatment plan, and related
   conditions of the Agreement.                                pharmaceutical and laboratory services to
                                                               the extent the benefit would have been
       Copayment: $15 per visit.                               provided had the Member remained in
                                                               the hospital, except as excluded in the
                                                               General Exclusions and Limitations. This
                                                               benefit includes: parenteral and enteral nutri-


                                                    27
BASIC PLAN
       tional services and associated supplies and sup-        L. Physical and Occupational Therapy
       plements.                                               Rehabilitation services include physical therapy,
                                                               occupational therapy, and/or respiratory therapy
        Copayment: No charge.
                                                               pursuant to a written treatment plan for as long
                                                               as continued treatment is medically necessary,
Skilled Nursing Services. A level of care that in-
                                                               and when rendered in the provider’s office or
cludes services that can only be performed
                                                               outpatient department of a hospital. Benefits for
safely and correctly by a licensed nurse (either a
                                                               speech therapy are described in Section M.
registered nurse or a licensed practical nurse).
                                                               Medically necessary services will be authorized
See Section O. for a specialized description of                for an initial treatment period and any additional
skilled nursing services for hospice care.                     subsequent medically necessary treatment peri-
                                                               ods if after conducting a review of the initial and
For information concerning “Hospice Program                    each additional subsequent period of care, it is
Services” see Section O.                                       determined that continued treatment is medi-
                                                               cally necessary and is provided with the expecta-
2. PKU-Related Formulas and Special Food                       tion that the patient has restorative potential.
   Products
                                                                       Copayment: No charge for inpatient
    Benefits are provided for enteral formulas                         therapy. $15 per visit for therapy pro-
    and special food products that are medically                       vided in the home or other outpatient
                                                                       setting.
    necessary to avert the development of seri-
    ous physical or mental disabilities or to
                                                               See Section K. for information on coverage for
    promote normal development or function
                                                               rehabilitation services rendered in the home.
    as a consequence of phenylketonuria (PKU).
    These benefits must be prior authorized by
                                                               M. Speech Therapy
    Blue Shield and must be prescribed or or-
    dered by the appropriate health care profes-               Initial outpatient benefits for speech therapy
    sional.                                                    services when diagnosed and ordered by a phy-
                                                               sician and provided by an appropriately licensed
        Copayment: No charge.                                  speech therapist, pursuant to a written treatment
                                                               plan for an appropriate time to: (1) correct or
3. Home Infusion/IV Injectable Therapy Pro-                    improve the speech abnormality, or (2) evaluate
   vided by a Home Infusion Agency                             the effectiveness of treatment, and when ren-
                                                               dered in the provider’s office or outpatient de-
    Benefits are provided for home infusion                    partment of a hospital.
    therapy and medical supplies, including the
    cost of pharmaceuticals administered intra-                Services are provided for the correction of, or
    venously; and for medically necessary, FDA                 clinically significant improvement of, speech
    approved injectable medications, when pre-                 abnormalities that are the likely result of a diag-
    scribed by the Personal Physician and prior                nosed and identifiable medical condition, illness,
    authorized.                                                or injury to the nervous system or to the vocal,
                                                               swallowing, or auditory organs.
    This benefit does not include insulin or
    home self-administered injectables, which                  Continued outpatient benefits will be provided
    are covered under Section P.                               for medically necessary services as long as con-
                                                               tinued treatment is medically necessary, pursu-
        Copayment: No charge.                                  ant to the treatment plan, and likely to result in
                                                               clinically significant progress as measured by ob-
For information concerning diabetes self-                      jective and standardized tests. The provider’s
management training, see Section V.                            treatment plan and records will be reviewed pe-
                                                               riodically. When continued treatment is not


                                                          28
BASIC PLAN
medically necessary pursuant to the treatment              in a hospice program can receive a pre-hospice
plan, not likely to result in additional clinically        consultative visit from a participating hospice
significant improvement, or no longer requires             agency.) Covered services are available on a 24-
skilled services of a licensed speech therapist,           hour basis to the extent necessary to meet the
the Member will be notified of this determina-             needs of individuals for care that is reasonable
tion and benefits will not be provided for ser-            and necessary for the palliation and manage-
vices rendered after the date of written                   ment of terminal illness and related conditions.
notification.                                              Members can continue to receive covered ser-
                                                           vices that are not related to the palliation and
Except as specified above and as stated under              management of the terminal illness from the
Section K., no outpatient benefits are provided            appropriate Plan provider. Member copayments
for speech therapy, speech correction, or speech           when applicable are paid to the participating
pathology services.                                        hospice agency.

        Copayment: No charge for inpatient                 Note: Hospice services provided by a non-
        therapy. $15 per visit for therapy pro-            participating hospice agency are not covered ex-
        vided in the home or other outpatient              cept in certain circumstances in counties in Cali-
        setting.                                           fornia in which there are no participating
                                                           hospice agencies. If Blue Shield prior authorizes
See Section K. for information on coverage for             hospice program services from a non-contracted
speech therapy services rendered in the home.              hospice, the Member’s copayment for these ser-
See Section A. for information on inpatient                vices will be the same as the copayments for
benefits and Section O. for hospice program                hospice program services when received and au-
services.                                                  thorized by a participating hospice agency.
N. Skilled Nursing Facility Services                       All of the services listed below must be received
Subject to all of the inpatient hospital services          through the participating hospice agency.
provisions under Section A., medically necessary
skilled nursing services, including subacute care,         1. Pre-hospice consultative visit regarding pain
will be covered when provided in a skilled nurs-              and symptom management, hospice and
ing facility and authorized. This benefit is lim-             other care options including care planning
ited to 100 days during any calendar year except              (Members do not have to be enrolled in the
when received through a hospice program pro-                  hospice program to receive this benefit).
vided by a participating hospice agency. Custo-
dial care is not covered.                                  2. Interdisciplinary Team care with develop-
                                                              ment and maintenance of an appropriate
For information concerning “Hospice Program                   plan of care and management of terminal
Services” see Section O.                                      illness and related conditions.

        Copayment: No charge.                              3. Skilled nursing services, certified health aide
                                                              services and homemaker services under the
O. Hospice Program Services                                   supervision of a qualified registered nurse.
Benefits are provided for the following services
through a participating hospice agency when an             4. Bereavement services.
eligible Member requests admission to and is
formally admitted to an approved hospice pro-              5. Social services/counseling services with
gram. The Member must have a terminal illness                 medical social services provided by a quali-
as determined by his Plan provider’s certifica-               fied social worker. Dietary counseling, by a
tion and the admission must receive prior ap-                 qualified provider, shall also be provided
proval from Blue Shield. (Note: Members with                  when needed.
a terminal illness who have not elected to enroll


                                                      29
BASIC PLAN
6. Medical direction with the medical director             Member. These services shall include an assess-
   being also responsible for meeting the gen-             ment of the needs of the bereaved family and
   eral medical needs for the terminal illness of          the development of a care plan that meets these
   the Members to the extent that these needs              needs, both prior to, and following the death of
   are not met by the Personal Physician.                  the Member.

7. Volunteer services.                                     Continuous Home Care - home care provided
                                                           during a period of crisis. A minimum of 8 hours
8. Short-term inpatient care arrangements.                 of continuous care, during a 24-hour day, be-
                                                           ginning and ending at midnight is required. This
9. Pharmaceuticals, medical equipment and                  care could be 4 hours in the morning and an-
   supplies that are reasonable and necessary              other 4 hours in the evening. Nursing care must
   for the palliation and management of termi-             be provided for more than half of the period of
   nal illness and related conditions.                     care and must be provided by either a registered
                                                           nurse or licensed practical nurse. Homemaker
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


                                                      30
BASIC PLAN
1. Considers the Member and the Member’s                  to the Interdisciplinary Team, a consultant to
   family in addition to the Member, as the               the Member’s Personal Physician, as requested,
   unit of care.                                          with regard to pain and symptom management,
                                                          and liaison with physicians and surgeons in the
2. Utilizes an Interdisciplinary Team to assess           community. For purposes of this section, the
   the physical, medical, psychological, social           person providing these services shall be referred
   and spiritual needs of the Member and the              to as the “medical director”.
   Member’s family.
                                                          Period of Care - the time when the Personal
3. Requires the Interdisciplinary Team to de-             Physician recertifies that the Member still needs
   velop an overall plan of care and to provide           and remains eligible for hospice care even if the
   coordinated care which emphasizes suppor-              Member lives longer than 1 year. A period of
   tive services, including, but not limited to,          care starts the day the Member begins to receive
   home care, pain control, and short-term in-            hospice care and ends when the 90 or 60-day
   patient services. Short-term inpatient ser-            period has ended.
   vices are intended to ensure both continuity
   of care and appropriateness of services for            Period of Crisis - a period in which the Mem-
   those Members who cannot be managed at                 ber requires continuous care to achieve pallia-
   home because of acute complications or the             tion or management of acute medical
   temporary absence of a capable primary                 symptoms.
   caregiver.
                                                          Plan of Care - a written plan developed by the
4. Provides for the palliative medical treatment          attending physician and surgeon, the “medical
   of pain and other symptoms associated with             director” (as defined under “Medical Direc-
   a terminal disease, but does not provide for           tion”) or physician and surgeon designee, and
   efforts to cure the disease.                           the Interdisciplinary Team that addresses the
                                                          needs of a Member and family admitted to the
5. Provides for bereavement services following            hospice program. The hospice shall retain over-
   the Member’s death to assist the family to             all responsibility for the development and main-
   cope with social and emotional needs asso-             tenance of the plan of care and quality of
   ciated with the death of the Member.                   services delivered.

6. Actively utilizes volunteers in the delivery of        Respite Care Services - short-term inpatient
   hospice services.                                      care provided to the Member only when neces-
                                                          sary to relieve the family members or other per-
7. Provides services in the Member’s home or              sons caring for the Member.
   primary place of residence to the extent ap-
   propriate based on the medical needs of the            Skilled Nursing Services - nursing services
   Member.                                                provided by or under the supervision of a regis-
                                                          tered nurse under a plan of care developed by
8. Is provided through a participating hospice            the Interdisciplinary Team and the Member’s
   agency.                                                Plan provider to a Member and his family that
                                                          pertain to the palliative, supportive services re-
Interdisciplinary Team - the hospice care                 quired by a Member with a terminal illness.
team that includes, but is not limited to, the            Skilled nursing services include, but are not lim-
Member and the Member’s family, a physician               ited to, Member assessment, evaluation and case
and surgeon, a registered nurse, a social worker,         management of the medical nursing needs of
a volunteer, and a spiritual caregiver.                   the Member, the performance of prescribed
                                                          medical treatment for pain and symptom con-
Medical Direction - services provided by a li-            trol, the provision of emotional support to both
censed physician and surgeon who is charged               the Member and his family, and the instruction
with the responsibility of acting as a consultant

                                                     31
BASIC PLAN
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. Selected drugs and drug
priate community resources, and maximize                           dosages and most home self-administered in-
positive aspects and opportunities for growth.                     jectables require prior authorization by Blue
                                                                   Shield for medical necessity, appropriateness of
Terminal Disease or Terminal Illness - a                           therapy or when effective, lower cost alterna-
medical condition resulting in a prognosis of life                 tives are available (the more costly alternative
of 1 year or less, if the disease follows its natural              will be authorized when medically necessary).
course.
                                                                   Smoking cessation drugs are covered for Mem-
Volunteer Services - services provided by                          bers after completion of smoking cessation
trained hospice volunteers who have agreed to                      classes or programs. This benefit is limited to
provide service under the direction of a hospice                   one course of treatment per calendar year.
staff member who has been designated by the                        Members may contact their medical group or
hospice to provide direction to hospice volun-                     IPA for information about these classes and
teers. Hospice volunteers may provide support                      programs. Blue Shield will reimburse the cost of
and companionship to the Member and his fam-                       the drugs only, minus the copayment, after re-
ily during the remaining days of the Member’s                      ceiving a copy of a certificate of completion for
life and to the surviving family following the                     a smoking cessation class or program. Partici-
Member’s death.                                                    pants are responsible for the cost of the smok-
                                                                   ing cessation class or program. If you have a
         Copayment: No charge.                                     question about the smoking cessation benefit,
                                                                   you should call Blue Shield Member Services at
P. Prescription Drugs                                              1-800-334-5847.
Except for the calendar year maximum copayments and
the Coordination of Benefits provision, the general provi-         Outpatient Drug Formulary
sions and exclusions of the HMO Health Plan Agree-                 Medications are selected for inclusion in Blue
ment shall apply.                                                  Shield’s Outpatient Drug Formulary based on
                                                                   safety, efficacy, FDA bioequivalency data and
This plan's prescription drug coverage is on average               then cost. New drugs and clinical data are re-
equivalent to or better than the standard benefit set by           viewed regularly to update the Formulary. Drugs
the federal government for Medicare Part D (also called            considered for inclusion or exclusion from the
creditable coverage). Because this Plan’s prescription drug        Formulary are reviewed by Blue Shield’s Phar-
coverage is creditable, you do not have to enroll in Medi-         macy and Therapeutics Committee during
care Part D while you maintain this coverage; however,             scheduled meetings four times a year.
you should be aware that if you have a subsequent break
in this coverage of 63 days or more before enrolling in            Members may call Blue Shield Member Services
Medicare Part D you could be subject to payment of                 at the number listed on their Blue Shield Identi-
higher Part D premiums.                                            fication Card to inquire if a specific drug is in-
                                                                   cluded in the Formulary. Member Services can
Benefits are provided for outpatient prescription                  also provide Members with a printed copy of
drugs which meet all of the requirements speci-                    the Formulary. Members may also access the

                                                              32
BASIC PLAN
Formulary through the Blue Shield of California           drugs which are medically necessary, adminis-
Web site at http://www.blueshieldca.com.                  tered more often than once a month by patient
                                                          or family member, administered subcutaneously
Benefits may be provided for non-Formulary                or intramuscularly, deemed safe for self-
drugs subject to higher copayments.                       administration as determined by Blue Shield’s
                                                          Pharmacy and Therapeutics Committee, prior
Definitions                                               authorized by Blue Shield and obtained from a
Brand Name Drugs - FDA approved drugs                     Blue Shield specialty pharmacy. Intravenous
under patent to the original manufacturer and             (IV) medications (i.e. those medications admin-
only available under the original manufacturer's          istered directly into a vein) are not considered
branded name.                                             home self-administered injectable drugs. Home
                                                          self-administered injectables are listed in Blue
Drugs - (1) drugs which are approved by the               Shield’s Outpatient Drug Formulary.
Food and Drug Administration (FDA), requir-
ing a prescription either by federal or California        Home self-administered injectables purchased
law, (2) insulin, and disposable hypodermic insu-         from other pharmacies are not covered.
lin needles and syringes, (3) pen delivery systems
for the administration of insulin as determined           Non-Formulary Drugs - drugs determined by
by Blue Shield to be medically necessary,                 Blue Shield's Pharmacy and Therapeutics Com-
(4) diabetic testing supplies (including lancets,         mittee as being duplicative or as having pre-
lancet puncture devices, and blood and ketone             ferred Formulary drug alternatives available.
urine testing strips and test tablets in medically        Benefits may be provided for non-Formulary
appropriate quantities for the monitoring and             drugs and are always subject to the non-
treatment of insulin dependent, non-insulin de-           Formulary copayment.
pendent and gestational diabetes), (5) oral,
transdermal patch, and vaginal ring contracep-            Non-Participating Pharmacy - a pharmacy
tives and diaphragms, and (6) inhalers and in-            which does not participate in the Blue Shield
haler spacers for the management and treatment            Pharmacy Network.
of asthma. Note: No prescription is necessary
to purchase the items shown in (2), (3) and (4);          Participating Pharmacy - a pharmacy which
however, in order to be covered these items               participates in the Blue Shield Pharmacy Net-
must be ordered by your provider.                         work. These participating pharmacies have
                                                          agreed to a contracted rate for covered prescrip-
Formulary - a comprehensive list of drugs                 tions for Blue Shield Members.
maintained by Blue Shield's Pharmacy and
Therapeutics Committee for use under the Blue             To select a participating pharmacy, the Member
Shield Prescription Drug Program, which is de-            may go to http://www.blueshieldca.com or call
signed to assist physicians in prescribing drugs          Member Services at 1-800-334-5847.
that are medically necessary and cost effective.
The Formulary is updated periodically. If not             Specialty Pharmacy Network - select partici-
otherwise excluded, the Formulary includes all            pating pharmacies contracted by Blue Shield to
generic drugs.                                            provide covered home self-administered in-
                                                          jectables. These pharmacies offer 24-hour clini-
Generic Drugs - drugs that (1) are approved by            cal services and provide prompt home delivery
the FDA as a therapeutic equivalent to the                of home self-administered injectables.
brand name drug, (2) contain the same active
ingredient as the brand name drug, and (3) cost           To select a specialty pharmacy, the Member may
less than the brand name drug equivalent.                 go to http://www.blueshieldca.com or call
                                                          Member Services at 1-800-334-5847.
Home Self-Administered Injectables - home
self-administered injectables are defined as those


                                                     33
BASIC PLAN
Obtaining Outpatient Prescription                          determined by Blue Shield’s Pharmacy and
Drugs at a Participating Pharmacy                          Therapeutics Committee.
1. To obtain drugs at a participating pharmacy,
   the Member must present his Blue Shield              4. If the Member requests a brand name drug
   Identification Card. Note: Except for cov-              when a generic drug equivalent is available,
   ered emergencies, claims for drugs obtained             the Member is responsible for paying the
   without using the Identification Card will be           difference between the participating phar-
   denied.                                                 macy contracted rate for the brand name
                                                           drug and its generic drug equivalent, as well
2. Benefits are provided for home self-                    as the applicable generic drug copayment.
   administered injectables only when obtained
   from a Blue Shield specialty pharmacy, ex-           5. If the prescription specifies a brand name
   cept in the case of an emergency. In the                drug and the prescribing provider has writ-
   event of an emergency, covered home self-               ten “Dispense As Written” or “Do Not
   administered injectables that are needed                Substitute” on the prescription, or if a ge-
   immediately may be obtained from any par-               neric drug equivalent is not available, the
   ticipating pharmacy, or, if necessary from a            Member is responsible for paying the appli-
   non-participating pharmacy.                             cable brand name drug copayment.

3. The Member is responsible for paying the             6. If the provider determines that use of a
   applicable copayment for each covered new               Formulary alternative is not appropriate for
   and refill prescription drug. The pharmacist            the Member, the provider may request ap-
   will collect from the Member the applicable             proval of a medically appropriate non-
   copayment at the time the drugs are ob-                 Formulary drug by Blue Shield. See the sec-
   tained.                                                 tion below on Approval of Non-Formulary
                                                           Drugs for information on the approval
       Copayment: $5 generic, $15 brand                    process. If Blue Shield approves this re-
       name*, $45 non-Formulary per pre-                   quest, the copayment for this non-
       scription for the amount prescribed                 Formulary drug is $30.
       not to exceed a 30-day supply.
                                                        7. The Member is responsible for paying a co-
   *For diabetic supplies (including disposable            payment of $30 for each prescription for
   insulin needles and syringes), diaphragms               home self-administered injectables, includ-
   and smoking cessation therapy drugs, the                ing any combination kit or package contain-
   Formulary brand name copayment applies.                 ing both oral and home self-administered
                                                           injectable drugs.
   If the participating pharmacy contracted rate
   charged by the participating pharmacy is less        8. Drugs obtained at a non-participating
   than or equal to the Member copayment,                  pharmacy are not covered, unless medically
   the Member will only be required to pay the             necessary for a covered emergency, includ-
   participating pharmacy contracted rate.                 ing drugs for emergency contraception. If
                                                           the Member must obtain drugs from a non-
   Prescription drugs administered in a physi-             participating pharmacy due to an emer-
   cian’s office, except immunizations, are cov-           gency, the submission of a Prescription
   ered by the $15 copayment for the office                Drug Claim is required. Claim forms are
   visit and do not require another copayment.             available by contacting Member Services.
                                                           Submit completed Prescription Drug Claim
   Some prescriptions are limited to a maxi-               form noting "Emergency Request" on form
   mum allowable quantity based on medical                 to Blue Shield Pharmacy Services, P.O. Box
   necessity and appropriateness of therapy as             7168, San Francisco, CA 94120. Claims
                                                           must be received within 1 year from the


                                                   34
BASIC PLAN
   date of service to be considered for pay-               *For diabetic supplies (including disposable
   ment. Reimbursement for covered emer-                   insulin needles and syringes), the Formulary
   gency claims will be based upon the                     brand name copayment applies.
   purchase price of covered prescription
   drug(s) less any applicable copayment(s).               If the participating pharmacy contracted rate
                                                           is less than or equal to the Member copay-
Obtaining Outpatient Prescription                          ment, the Member will only be required to
Drugs Through the Mail Service                             pay the participating pharmacy contracted
Prescription Drug Program                                  rate.
1. For the Member’s convenience, when drugs
   have been prescribed for a chronic condi-            3. If the Member requests a mail service brand
   tion and the Member's medication dosage                 name drug when a mail service generic drug
   has been stabilized, he may obtain the drug             equivalent is available, the Member is re-
   through Blue Shield's Mail Service Prescrip-            sponsible for the difference between the
   tion Drug Program. Prior to using this Mail             contracted rate for the mail service brand
   Service Program, the Member must have re-               name drug and its mail service generic drug
   ceived the same medication and dosage                   equivalent, as well as the applicable mail
   through the Blue Shield Pharmacy Network                service generic drug copayment.
   for at least 2 months. Blue Shield will pro-
                                                        4. If the prescription specifies a mail service
   vide mail order forms and information at
                                                           brand name drug and the prescribing pro-
   the time of enrollment. The Member should
                                                           vider has written “Dispense As Written” or
   submit the applicable copayment, an order
                                                           “Do Not Substitute” on the prescription, or
   form and his Blue Shield Member number
                                                           if a mail service generic drug equivalent is
   to the address indicated on the mail order
                                                           not available, the Member is responsible for
   envelope. Be sure to send in your refill re-
                                                           paying the applicable mail service brand
   quest approximately 3 weeks before your
                                                           name drug copayment.
   supply runs out. Members should allow 14
   days to receive the drug. The Member’s
                                                        5. If the provider determines that use of a
   provider must indicate a prescription quan-
                                                           Formulary alternative is not appropriate for
   tity which is equal to the amount to be dis-
                                                           the Member, the provider may request ap-
   pensed. Home self-administered injectables,
                                                           proval of a medically appropriate non-
   except for insulin, are not available through
                                                           Formulary drug by Blue Shield. See the sec-
   the Mail Service Prescription Drug Program.
                                                           tion below on Approval of Non-Formulary
                                                           Drugs for information on the approval
2. The Member is responsible for paying the
                                                           process. If Blue Shield approves this re-
   applicable copayment for each covered new
                                                           quest, the copayment for this non-
   and refill prescription drug. Copayments will
                                                           Formulary drug is $45.
   be tracked for the Member.

       Copayment: $10 generic, $25 brand
                                                        6. For information about the Mail Service Pre-
       name*, $75 non-Formulary per pre-                   scription Drug Program, the Member may
       scription not to exceed a 90-day sup-               refer to the mail service program brochure
       ply; $1,000 out-of-pocket annual                    for the phone number and a more detailed
       maximum, then no charge. If the                     explanation or call Blue Shield Member Ser-
       Member’s provider indicates a pre-                  vices at 1-800-334-5847.
       scription quantity of less than a 90-day
       supply, that amount will be dispensed            Approval of Non-Formulary Drugs
       and refill authorizations cannot be              A non-Formulary drug may be covered at a
       combined to reach a 90-day supply.               lower copayment as described above. Your pro-
                                                        vider may request approval from Blue Shield
                                                        Pharmacy Services. After all necessary docu-


                                                   35
BASIC PLAN
mentation is available from your provider, ap-                  drugs for emergency contraception, and
proval or denial will be provided to your pro-                  drugs obtained outside of California which
vider within 2 working days of the request.                     are related to an urgently needed service and
Non-Formulary drugs that are not specifically                   for which a participating pharmacy was not
listed as exclusions herein may be considered for               reasonably accessible;
approval in these situations:
                                                            2. Any drug provided or administered while
1. When no Formulary alternative is appropri-                  the Member is an inpatient, or in a pro-
   ate and the drug is considered to be medi-                  vider's office (see A. Hospital Services and
   cally necessary for you, as determined by                   B. Physician Services);
   Blue Shield. Your provider may be required
   to submit persuasive evidence in the form                3. Take home drugs received from a hospital,
   of studies, records or documents showing                    convalescent home, skilled nursing facility,
   that use of the requested non-Formulary                     or similar facility (see A. Hospital Services
   drug over a Formulary drug is medically                     and N. Skilled Nursing Facility Services);
   necessary;
                                                            4. Except as specifically listed as covered un-
2. When you have failed treatment or have ex-                  der this Section P., drugs which can be ob-
   perienced adverse effects with the Formu-                   tained without a prescription or for which
   lary drug. Blue Shield will request your                    there is a non-prescription drug that is the
   provider to provide clinical information that               identical chemical equivalent (i.e., same ac-
   documents treatment failure or adverse ef-                  tive ingredient and dosage) to a prescription
   fects with a Formulary alternative;                         drug;

3. When your treatment is stable with a non-                5. Drugs for which the Member is not legally
   Formulary drug and conversion to a Formu-                   obligated to pay, or for which no charge is
   lary drug would be medically inappropriate.                 made;

If, after review, it is determined that a Formu-            6. Drugs that are considered to be experimen-
lary alternative in this instance is not appropriate           tal or investigational;
for you, the non-Formulary drug will be ap-
proved and be covered at the lower copayment                7. Medical devices or supplies, except as spe-
of $30 at the participating pharmacy or $45                    cifically listed as covered herein (see E. Du-
through mail service. If, however, it is deter-                rable Medical Equipment, Prostheses and
mined that the non-Formulary drug does not                     Orthoses and Other Services);
meet one of the three criteria described above,
then the non-Formulary drug will be covered at              8. Drugs when prescribed for cosmetic pur-
the higher copayment of $45 at the participating               poses, including but not limited to drugs
pharmacy or $75 through mail service.                          used to retard or reverse the effects of skin
                                                               aging or to treat hair loss;
Exclusions
No benefits are provided under the Prescription             9. Dietary or nutritional products (see K.
Drugs benefit for the following (please note,                  Home Health Care Services, PKU-Related
certain services excluded below may be covered                 Formulas and Special Food Products, and
under other benefits/portions of this Evidence                 Home Infusion Therapy);
of Coverage – you should refer to the applicable
                                                            10. Injectable drugs which are not self-
section to determine if drugs are covered under
                                                                administered. Other injectable medications
that benefit):
                                                                may be covered under Y. Additional Ser-
1. Drugs obtained from a non-participating                      vices;
   pharmacy, except for a covered emergency,


                                                       36
BASIC PLAN
11. Appetite suppressants or drugs for body                Participating Providers. (See the How to Use the
    weight reduction except when medically                 Plan section, the Mental Health and Substance
    necessary for the treatment of morbid obe-             Abuse Services paragraphs for more informa-
    sity. In such cases the drug will be subject to        tion.)
    prior authorization from Blue Shield;
                                                           Benefits are provided for the following medi-
12. Drugs when prescribed for smoking cessa-               cally necessary covered mental health and sub-
    tion purposes, except as provided under this           stance abuse services, subject to applicable
    Section P.;                                            copayments and charges in excess of any benefit
                                                           maximums. Coverage for these services is sub-
13. Compounded medications if: (1) there is a              ject to all terms, conditions, limitations and ex-
    medically appropriate Formulary alternative,           clusions of the Agreement, to any conditions or
    or, (2) there are no FDA-approved indica-              limitations set forth in the benefit description
    tions. Compounded medications that do not              below, and to the Exclusions and Limitations
    include at least one drug, as defined, are not         set forth in this booklet.
    covered;
                                                           Inpatient hospital and professional services in
14. Replacement of lost, stolen or destroyed               connection with hospitalization or psychiatric
    prescription drugs;                                    partial hospitalization, for the treatment of men-
                                                           tal illness (including treatment of severe mental
15. Drugs prescribed for treatment of dental               illnesses of a Member of any age and of serious
    conditions. This exclusion shall not apply to          emotional disturbances of a child), are covered.
    antibiotics prescribed to treat infection nor          All non-emergency mental health and substance
    to medications prescribed to treat pain.               abuse services must be prior authorized by the
                                                           MHSA and obtained from MHSA Participating
Call Member Services at 1-800-334-5847 for fur-            Providers. Residential care is not covered.
ther information.
                                                           See Section A. for information on medically
See the Grievance Process section of this Evi-             necessary inpatient substance abuse detoxifica-
dence of Coverage for information on filing a              tion.
grievance, your right to seek assistance from the
Department of Managed Health Care and your                         Copayment: No charge.
rights to independent medical review.
                                                           R. Outpatient Mental Health and
Q. Inpatient Mental Health and                                Substance Abuse Services
   Substance Abuse Services                                1. Medically necessary outpatient psychiatric
Blue Shield of California’s MHSA administers                  care for other than severe mental illnesses or
and delivers the Plan’s mental health and sub-                serious emotional disturbances of a child.
stance abuse benefits. These services are pro-                This benefit is limited to a combined maxi-
vided through a unique network of MHSA                        mum of 20 visits for diagnosis and treat-
Participating Providers. All non-emergency                    ment in any calendar year. Intensive
mental health and substance abuse services must               outpatient treatment is not covered under
be arranged through the MHSA. Also, all non-                  this benefit.
emergency mental health and substance abuse
services must be prior authorized by the MHSA.                     Copayment: $20 per visit.
For prior authorization for mental health and
substance abuse services, Members should con-              2. Medically necessary outpatient psychiatric
tact the MHSA at 1-866-505-3409.                              care for the diagnosis and treatment of se-
                                                              vere mental illnesses of a Member of any
All non-emergency mental health and substance                 age and of serious emotional disturbances of
abuse services must be obtained from MHSA                     a child. Intensive outpatient care and psy-


                                                      37
BASIC PLAN
    chological testing are covered under this               5. Medically necessary treatment of maxilla and
    benefit.                                                   mandible (jaw joints and jaw bones); or

        Copayment: $15 per visit.                           6. Orthognathic surgery (surgery to reposition
                                                               the upper and/or lower jaw) which is medi-
3. Crisis intervention and treatment for sub-                  cally necessary to correct skeletal deformity.
   stance abuse on an outpatient basis as medi-
   cally appropriate. This benefit is limited to                    Copayment: See applicable copay-
   20 visits per calendar year.                                     ments for Physician Services and Hos-
                                                                    pital Services.
        Copayment: $15 per visit.
                                                            This benefit does not include:
4. Psychosocial Support
                                                            1. Services performed on the teeth, gums
    See the Mental Health and Substance Abuse                  (other than tumors) and associated perio-
    Services paragraphs under the How to Use                   dontal structures, routine care of teeth and
    the Plan section for information on psycho-                gums, diagnostic services, preventive or pe-
    social support services available under                    riodontic services, dental orthosis and pros-
    Lifepath Advisers.                                         thesis, including hospitalization incident
                                                               thereto;
        Copayment: No charge.
                                                            2. Orthodontia (dental services to correct ir-
S. Medical Treatment of the Teeth,                             regularities or malocclusion of the teeth) for
   Gums, Jaw Joints or Jaw Bones                               any reason, including treatment to alleviate
Hospital and professional services provided for                TMJ;
conditions of the teeth, gums or jaw joints and
jaw bones, including adjacent tissues are a bene-           3. Any procedure (e.g., vestibuloplasty) in-
fit only to the extent that they are provided for:             tended to prepare the mouth for dentures or
                                                               for the more comfortable use of dentures;
1. The treatment of tumors of the gums;
                                                            4. Dental implants (endosteal, subperiosteal or
2. The treatment of damage to natural teeth                    transosteal);
   caused solely by an accidental injury is lim-
   ited to medically necessary services until the           5. Alveolar ridge surgery of the jaws if per-
   services result in initial, palliative stabiliza-           formed primarily to treat diseases related to
   tion of the Member as determined by the                     the teeth, gums or periodontal structures or
   Plan;                                                       to support natural or prosthetic teeth;

    Dental services provided after initial medical          6. Fluoride treatments except when used with
    stabilization, prosthodontics, orthodontia                 radiation therapy to the oral cavity.
    and cosmetic services are not covered. This
    benefit does not include damage to the                  See the Exclusions and Limitations section for
    natural teeth that is not accidental (e.g., re-         additional services that are not covered.
    sulting from chewing or biting).
                                                            T. Special Transplant Benefits
3. Medically necessary non-surgical treatment               Benefits are provided for certain procedures
   (e.g., splint and physical therapy) of Tem-              listed below only if: (1) performed at a Trans-
   poromandibular Joint Syndrome (TMJ);                     plant Network Facility approved by Blue Shield
                                                            of California to provide the procedure, (2) prior
4. Surgical and arthroscopic treatment of TMJ               authorization is obtained, in writing, from the
   if prior history shows conservative medical              Blue Shield Corporate Medical Director, and
   treatment has failed;                                    (3) the recipient of the transplant is a Member.

                                                       38
BASIC PLAN
The Blue Shield Corporate Medical Director                7. Pediatric human small bowel transplants;
shall review all requests for prior authorization
and shall approve or deny benefits, based on the          8. Pediatric and adult human small bowel and
medical circumstances of the patient, and in ac-             liver transplants in combination.
cordance with established Blue Shield medical
policy. Failure to obtain prior written authoriza-        Reasonable charges for services incident to ob-
tion as described above and/or failure to have            taining the transplanted material from a living
the procedure performed at a Blue Shield ap-              donor or an organ transplant bank will be cov-
proved Transplant Network Facility will result            ered.
in denial of claims for this benefit.
                                                                  Copayment: Physician Services and
Pre-transplant evaluation and diagnostic tests,                   Hospital Services copayments apply.
transplantation and follow-ups will be allowed
only at a Blue Shield approved Transplant Net-            U. Organ Transplant Benefits
work       Facility. Non-acute/non-emergency              Hospital and professional services provided in
evaluations, transplantations and follow-ups at           connection with human organ transplants are a
facilities other than a Blue Shield Transplant            benefit to the extent that they are provided in
Network Facility will not be approved. Evalua-            connection with the transplant of a cornea, kid-
tion of potential candidates at a Blue Shield             ney, or skin, and the recipient of such transplant
Transplant Network Facility is covered subject            is a Member.
to prior authorization. In general, more than
one evaluation (including tests) within a short           Services incident to obtaining the human organ
time period and/or more than one Transplant               transplant material from a living donor or an or-
Network Facility will not be authorized unless            gan transplant bank will be covered.
the medical necessity of repeating the service is
documented and approved. For information on                       Copayment: Physician Services and
Blue Shield of California’s approved Transplant                   Hospital Services copayments apply.
Network, call 1-800-334-5847.
                                                          V. Diabetes Care
The following procedures are eligible for cover-          1. Diabetic Equipment
age under this provision:
                                                              Benefits are provided for the following de-
1. Human heart transplants;                                   vices and equipment, including replacement
                                                              after the expected life of the item and when
2. Human lung transplants;                                    medically necessary, for the management
                                                              and treatment of diabetes when medically
3. Human heart and lung transplants in com-                   necessary and authorized:
   bination;
                                                              a. blood glucose monitors, including those
4. Human liver transplants;                                      designed to assist the visually impaired;

5. Human kidney and pancreas transplants in                   b. insulin pumps and all related necessary
   combination (kidney only transplants are                      supplies;
   covered under Section U.);
                                                              c. podiatric devices to prevent or treat dia-
6. Human bone marrow transplants, including                      betes-related complications, including ex-
   autologous bone marrow transplantation or                     tra-depth orthopedic shoes;
   autologous peripheral stem cell transplanta-               d. visual aids, excluding eyewear and/or
   tion used to support high-dose chemother-                     video-assisted devices, designed to assist
   apy when such treatment is medically                          the visually impaired with proper dosing
   necessary and is not experimental or investi-                 of insulin;
   gational;

                                                     39
BASIC PLAN
    e. for coverage of diabetic testing supplies          or repair abnormal structures of the body
       including blood and urine testing strips           caused by congenital defects, developmental ab-
       and test tablets, lancets and lancet punc-         normalities, trauma, infection, tumors, or dis-
       ture devices and pen delivery systems for          ease, and which will result in more than minimal
       the administration of insulin, see Section         improvement in function or appearance:
       P.
                                                          1. Surgery to excise, enlarge, reduce, or change
        Copayment: No charge.                                the appearance of any part of the body;
2. Diabetes Self-Management Training                      2. Surgery to reform or reshape skin or bone;
    Diabetes outpatient self-management train-            3. Surgery to excise or reduce skin or connec-
    ing, education and medical nutrition therapy             tive tissue that is loose, wrinkled, sagging, or
    that is medically necessary to enable a                  excessive on any part of the body;
    Member to properly use the diabetes-related
    devices and equipment and any additional              4. Hair transplantation; and
    treatment for these services if directed or
    prescribed by the Member’s Personal Physi-            5. Upper eyelid blepharoplasty without docu-
    cian and authorized. These benefits shall in-            mented significant visual impairment or
    clude, but not be limited to, instruction that           symptomatology.
    will enable diabetic patients and their fami-
    lies to gain an understanding of the diabetic         This limitation shall not apply when breast re-
    disease process, and the daily management             construction is performed subsequent to a
    of diabetic therapy, in order to thereby              medically necessary mastectomy, including sur-
    avoid frequent hospitalizations and compli-           gery on either breast to achieve or restore sym-
    cations.                                              metry.

        Copayment: $15 per visit.                                 Copayment: Physician Services and
                                                                  Hospital Services copayments apply.
W. Reconstructive Surgery
Medically necessary services in connection with           X. Clinical Trials for Cancer
reconstructive surgery to correct or repair ab-           Benefits are provided for routine patient care
normal structures of the body and which result            for a Member whose Personal Physician has ob-
in more than a minimal improvement in func-               tained prior authorization and who has been ac-
tion or appearance (including congenital anoma-           cepted into an approved clinical trial for cancer
lies) are covered. In accordance with the                 provided that:
Women’s Health & Cancer Rights Act, surgi-
cally implanted and other prosthetic devices (in-         1. The clinical trial has a therapeutic intent and
cluding prosthetic bras) and reconstructive                  the Member’s treating physician determines
surgery on either breast provided to restore and             that participation in the clinical trial has a
achieve symmetry incident to a mastectomy are                meaningful potential to benefit the Member;
covered. Surgery must be authorized as de-                   with a therapeutic intent; and
scribed herein. Any such services must be re-
ceived while the Plan is in force with respect to         2. The Member’s treating physician recom-
the Member. Benefits will be provided in accor-              mends participation in the clinical trial; and
dance with guidelines established by the Plan
and developed in conjunction with plastic and             3. The hospital and/or physician conducting
reconstructive surgeons.                                     the clinical trial is a Plan provider, unless the
                                                             protocol for the trial is not available through
No benefits will be provided for the following               a Plan provider.
surgeries or procedures unless determined by
Blue Shield to be medically necessary to correct

                                                     40
BASIC PLAN
Services for routine patient care will be paid on            Y. Additional Services
the same basis and at the same benefit levels as             1. Personal Health Management Program
other covered services.
                                                                Health education and health promotion ser-
Routine patient care consists of those services                 vices provided by Blue Shield’s Center for
that would otherwise be covered by the Plan if                  Health Improvement offer a variety of well-
those services were not provided in connection                  ness resources including, but not limited to:
with an approved clinical trial, but does not in-               a member newsletter and a prenatal health
clude:                                                          education program.
1. Drugs or devices that have not been ap-                          Copayment: No charge.
   proved by the federal Food and Drug Ad-
   ministration (FDA);                                       2. Injectable Medications

2. Services other than health care services,                    Injectable medications approved by the
   such as travel, housing, companion expenses                  FDA are covered for the medically neces-
   and other non-clinical expenses;                             sary treatment of medical conditions when
                                                                prescribed or authorized by the Personal
3. Any item or service that is provided solely                  Physician or as described herein. See Section
   to satisfy data collection and analysis needs                P. for information on insulin and home self-
   and that is not used in the clinical manage-                 administered injectables coverage and co-
   ment of the patient;                                         payment.

4. Services that, except for the fact that they                     Copayment: No charge.
   are being provided in a clinical trial, are spe-
   cifically excluded under the Plan;                        3. Away From Home Care® Program

5. Services customarily provided by the re-                     The Blue Shield Access+ HMO offers to
   search sponsor free of charge for any enrol-                 CalPERS members who are long-term trav-
   lee in the trial.                                            elers, students and families living apart,
                                                                Away From Home Care (AFHC).
An approved clinical trial is limited to a trial that
is:                                                             AFHC offers full HMO benefits with a local
                                                                ID card. Membership eligibility is applicable
1. Approved by one of the following:                            to spouses, domestic partners and depend-
                                                                ents who are away from home for at least 90
    a. one of the National Institutes of Health;                days, or to members who are away from
                                                                home for at least 90 days but not more than
    b. the federal Food and Drug Administra-                    180 days. There is no additional charge to
       tion, in the form of an investigational                  the member. AFHC is coordinated by call-
       new drug application;                                    ing 1-800-334-5847.
    c. the United States Department of De-
       fense;                                                   AFHC also offers a special short-term ser-
                                                                vice which is available to members requiring
    d. the United States Veterans’ Administra-                  specific follow-up treatment. This option is
       tion; or                                                 particularly beneficial for members who will
                                                                be out-of-state on a short-term basis but re-
2. Involves a drug that is exempt under federal                 quire special treatment.
   regulations from a new drug application.

        Copayment: Physician Services and
        Hospital Services copayments apply.

                                                        41
BASIC PLAN
4. Hearing Aid Services                                   Member Maximum Calendar Year
                                                          Copayment
   a. Audiological Evaluation. To measure the             The Member maximum calendar year copay-
      extent of hearing loss and a hearing aid            ment responsibility for covered services exclud-
      evaluation to determine the most appro-             ing those specified, is listed in the Summary of
      priate make and model of hearing aid.               Covered Services. (Also, see the Member Maxi-
       Copayment: No charge. Evaluation is                mum Calendar Year Copayment paragraphs un-
       in addition to the $1,000 maximum al-              der How to Use the Plan.)
       lowed every 36 months for both ears
       for the hearing aid and ancillary                  Note that copayments and charges for services
       equipment.                                         not accruing to the Member maximum calendar
                                                          year copayment continue to be the Member’s
   b. Hearing Aid. Monaural or binaural in-               responsibility after the calendar year copayment
      cluding ear mold(s), the hearing aid in-            maximum is reached.
      strument, the initial battery, cords and
      other ancillary equipment. Includes visits          Exclusions and Limitations
      for fitting, counseling, adjustments, re-           General Exclusions and Limitations
      pairs, etc. at no charge for a 1-year pe-           Unless exceptions to the following exclusions
      riod following the provision of a covered           are specifically made elsewhere in the Agree-
      hearing aid.                                        ment, no benefits are provided for services
                                                          which are:
      Excludes the purchase of batteries or
      other ancillary equipment, except those             1. Acupuncture. For or incident to acupunc-
      covered under the terms of the initial                 ture;
      hearing aid purchase and charges for a
      hearing aid which exceed specifications             2. Behavioral Problems. For learning dis-
      prescribed for correction of a hearing                 abilities or behavioral problems;
      loss. Excludes replacement parts for
      hearing aids, repair of hearing aid after           3. Cosmetic Surgery. For cosmetic surgery,
      the covered 1-year warranty period and                 or any resulting complications, except medi-
      replacement of a hearing aid more than                 cally necessary services to treat complica-
      once in any period of 36 months. Also                  tions of cosmetic surgery (e.g., infections or
      excludes surgically implanted hearing de-              hemorrhages) will be a benefit, but only
      vices. Cochlear implants are not consid-               upon review and approval by a Blue Shield
      ered surgically implanted hearing devices              physician consultant. Without limiting the
      and are covered as a prosthetic under                  foregoing, no benefits will be provided for
      Section E.                                             the following surgeries or procedures:
       Limitations: Up to maximum of $1,000                   • Lower eyelid blepharoplasty;
       per Member every 36 months for both                    • Spider veins;
       ears for the hearing aid instrument,
                                                              • Procedures to smooth the skin (i.e.,
       and ancillary equipment.
                                                                chemical face peels, laser resurfacing,
   To receive these services, you may either                    and abrasive procedures);
   contact your Personal Physician to obtain a                • Hair removal by electrolysis or other
   referral or self-refer to an Access+ Specialist              means; and
   as described in the How to Use the Plan                    • Reimplantation of breast implants
   section.                                                     originally provided for cosmetic aug-
                                                                mentation;

                                                          4. Custodial or Domiciliary Care. For or in-
                                                             cident to services rendered in the home or

                                                     42
BASIC PLAN
    hospitalization or confinement in a health                treatment (other than surgery) of chronic
    facility primarily for custodial, maintenance             conditions of the foot, including but not
    or domiciliary care, except as provided un-               limited to weak or fallen arches, flat or pro-
    der O.; or rest;                                          nated foot, pain or cramp of the foot, bun-
                                                              ions, muscle trauma due to exertion or any
5. Dental Care, Dental Appliances. For den-                   type of massage procedure on the foot; spe-
   tal care or services incident to the treatment,            cial footwear (e.g., non-custom made or
   prevention or relief of pain or dysfunction                over-the-counter shoe inserts or arch sup-
   of the temporomandibular joint and/or                      ports), except as specifically provided under
   muscles of mastication, except as specifically             E. and V.;
   provided under S.; for or incident to ser-
   vices and supplies for treatment of the teeth          9. Genetic Testing. For genetic testing except
   and gums (except for tumors) and associ-                  as described under D. and F.;
   ated periodontal structures, including but
   not limited to diagnostic, preventive, ortho-          10. Home Monitoring Equipment. For home
   dontic, and other services such as dental                  testing devices and monitoring equipment,
   cleaning, tooth whitening, x-rays, topical                 except for use of the peak flow monitor for
   fluoride treatment except when used with                   self-management of asthma, the glucose
   radiation therapy to the oral cavity, fillings             monitor for self-management of diabetes
   and root canal treatment; treatment of                     and the apnea monitor for management of
   periodontal disease or periodontal surgery                 newborn apnea when authorized as durable
   for inflammatory conditions; tooth extrac-                 medical equipment;
   tion; dental implants; braces, crowns, dental
   orthoses and prostheses; except as specifi-            11. Infertility Reversal. For or incident to the
   cally provided under A. and S.;                            treatment of infertility or any form of as-
                                                              sisted reproductive technology, including
6. Experimental or Investigational Procedures.                but not limited to the reversal of a vasec-
   Experimental or investigational medicine,                  tomy or tubal ligation, or any resulting com-
   surgery or other experimental or investiga-                plications, except for medically necessary
   tional health care procedures as defined, ex-              treatment of medical complications;
   cept for services for Members who have
   been accepted into an approved clinical trial          12. Infertility Services. For any services related
   for cancer as provided under X.;                           to assisted reproductive technology, includ-
                                                              ing but not limited to the harvesting or
    See section entitled “External Independent                stimulation of the human ovum, ovum
    Medical Review” for information concern-                  transplants, in vitro fertilization, Gamete In-
    ing the availability of a review of services              trafallopian Transfer (GIFT) procedure, Zy-
    denied under this exclusion.                              gote Intrafallopian Transfer (ZIFT)
                                                              procedure or any other form of induced fer-
7. Eye Surgery. For surgery to correct refrac-                tilization (except for artificial insemination),
   tive error (such as but not limited to radial              services or medications to treat low sperm
   keratotomy, refractive keratoplasty), lenses               count or services incident to or resulting
   and frames for eyeglasses, contact lenses,                 from procedures for a surrogate mother
   except as provided under E., and video-                    who is otherwise not eligible for covered
   assisted visual aids or video magnification                pregnancy and maternity care under a Blue
   equipment for any purpose;                                 Shield of California health plan;

8. Foot Care. For routine foot care, including            13. Learning Disabilities. For testing for in-
   callus, corn paring or excision and toenail                telligence or learning disabilities;
   trimming (except as may be provided
   through a participating hospice agency);


                                                     43
BASIC PLAN
14. Limited or Excluded Services. Benefits               21. Penile Implant. For penile implant devices
    for services limited or excluded in your                 and surgery, and any related services except
    HMO health service plan; however, drugs                  for any resulting complications and medi-
    customarily provided by dentists and oral                cally necessary services as provided under
    surgeons, or customarily provided for nerv-              W.;
    ous or mental disorders, or incident to
    pregnancy, or customarily provided for sub-          22. Personal Comfort Items. Convenience
    stance abuse, or incident to physical therapy            items such as telephones, TVs, guest trays,
    are not excluded;                                        and personal hygiene items;

15. Miscellaneous Equipment. For orthope-                23. Physical Examinations. For physical ex-
    dic shoes except for therapeutic footwear                ams required for licensure, employment, or
    for diabetics and except as provided under               insurance unless the examination corre-
    V., environmental control equipment, gen-                sponds to the schedule of routine physical
    erators, exercise equipment, self-help/                  examinations provided under C.;
    educational devices, vitamins, any type of
    communicator, voice enhancer, voice pros-            24. Prescription Orders. Prescription orders
    thesis, electronic voice producing machine,              or refills which exceed the amount specified
    or any other language assistance devices, ex-            in the prescription, or prescription orders or
    cept as provided under E. and comfort                    refills dispensed more than a year from the
    items;                                                   date of the original prescription.

16. Nutritional and Food Supplements. For                    Prescription orders or refills in quantities
    prescription or non-prescription nutritional             exceeding a 30-day supply, except for mail
    and food supplements except as provided                  order.
    under K.;
                                                             Prescription orders or refills which are equal
17. Organ Transplants. Incident to an organ                  to or less than the amount of your copay-
    transplant, except as provided under T. and              ment.
    U.;
                                                         25. Private Duty Nursing. In connection with
18. 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             26. 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;

19. Over-the-Counter Medications. For over-              27. Reconstructive Surgery. For reconstruc-
    the-counter medications not requiring a pre-             tive surgery and procedures: (1) where there
    scription, except as provided for smoking                is another more appropriate surgical proce-
    cessation drugs;                                         dure that is approved by a Blue Shield phy-
                                                             sician consultant, or (2) when the surgery or
20. Pain Management. For or incident to                      procedure offers only a minimal improve-
    hospitalization or confinement in a pain                 ment in function or in the appearance of the
    management center to treat or cure chronic               enrollees, e.g., spider veins, or (3) as limited
    pain, except as may be provided through a                under W.;
    participating hospice agency and except as
    medically necessary;                                 28. Services by Close Relatives. Services per-
                                                             formed by a close relative or by a person

                                                    44
BASIC PLAN
    who ordinarily resides in the Member’s                37. Unauthorized Treatment. Not provided,
    home;                                                     prescribed, referred, or authorized as de-
                                                              scribed herein except for Access+ Specialist
29. Sex Transformations. For transgender or                   visits, OB/GYN services provided by an
    gender dysphoria conditions, including but                obstetrician/gynecologist or a family prac-
    not limited to, intersex surgery (transsexual             tice physician within the same medical
    operations), or any related services, or any              group or IPA as the Personal Physician,
    resulting medical complications, except for               emergency services or urgent services as
    treatment of medical complications that is                provided under the Agreement provisions,
    medically necessary;                                      when specific authorization has been ob-
                                                              tained in writing for such services as de-
30. Sexual Dysfunctions. For or incident to                   scribed herein, for mental health and
    sexual dysfunctions and sexual inadequacies,              substance abuse services which must be ar-
    except as provided for treatment of organi-               ranged through the MHSA or for hospice
    cally based conditions;                                   services received by a participating hospice
                                                              agency;
31. Speech Therapy. For or incident to speech
    therapy, speech correction or speech pa-              38. Workers’ Compensation/Work-Related Injury.
    thology or speech abnormalities that are not              For or incident to any injury or disease aris-
    likely the result of a diagnosed, identifiable            ing out of, or in the course of, any employ-
    medical condition, injury or illness, except              ment for salary, wage or profit if such injury
    as specifically provided under K., M. and                 or disease is covered by any workers’ com-
    O.;                                                       pensation law, occupational disease law or
                                                              similar legislation. However, if Blue Shield
32. Spinal Manipulation. For spinal manipula-                 provides payment for such services it will be
    tion or adjustment;                                       entitled to establish a lien upon such other
                                                              benefits up to the reasonable cash value of
33. Therapeutic Devices. Devices or appara-                   benefits provided by Blue Shield for the
    tuses, regardless of therapeutic effect (e.g.,            treatment of the injury or disease as re-
    hypodermic needles and syringes, except as                flected by the providers’ usual billed
    needed for insulin and covered injectable                 charges;
    medication), support garments and similar
    items;                                                39. Not Specifically Listed as a Benefit.
34. Transportation Services. For transporta-              See the Grievance Process section for informa-
    tion services other than provided for under           tion on filing a grievance, your right to seek as-
    H.;                                                   sistance from the Department of Managed
                                                          Health Care, and your rights to independent
35. Unapproved Drugs/Medicines. Drugs                     medical review.
    and medicines which cannot be lawfully
    marketed without approval of the U.S. Food            Medical Necessity Exclusion
    and Drug Administration (FDA); however,               All services must be medically necessary. The
    drugs and medicines which have received               fact that a physician or other provider may pre-
    FDA approval for marketing for one or                 scribe, order, recommend, or approve a service
    more uses will not be denied on the basis             or supply does not, in itself, make it medically
    that they are being prescribed for an off-            necessary, even though it is not specifically listed
    label use if the conditions set forth in Cali-        as an exclusion or limitation. Blue Shield may
    fornia Health & Safety Code Section                   limit or exclude benefits for services which are
    1367.21 have been met;                                not medically necessary.
36. Unauthorized Non-Emergency Services.
    For unauthorized non-emergency services;

                                                     45
BASIC PLAN
Limitations for Duplicate Coverage                              this exclusion does not apply to Medi-Cal;
In the event that you are covered under the Plan                or Subchapter 19 (commencing with Section
and are also entitled to benefits under any of the              1396) of Chapter 7 of Title 42 of the United
conditions listed below, Blue Shield’s liability for            States Code; or for the reasonable costs of
services (including room and board) provided to                 services provided to the person at a Veter-
the Member for the treatment of any one illness                 ans Administration facility for a condition
or injury shall be reduced by the amount of                     unrelated to military service or at a Depart-
benefits paid, or the reasonable value or the                   ment of Defense facility, provided the per-
amount of Blue Shield’s fee-for-service payment                 son is not on active duty.
to the provider, whichever is less, of the services
provided without any cost to you, because of                Exception for Other Coverage
your entitlement to such other benefits. This ex-           A Plan provider may seek reimbursement from
clusion is applicable to benefits received from             other third party payors for the balance of its
any of the following sources:                               reasonable charges for services rendered under
                                                            this Plan.
1. Benefits provided under Title 18 of the So-
   cial Security Act (“Medicare”). If a Member              Claims and Services Review
   receives services to which he is entitled un-            Blue Shield reserves the right to review all
   der Medicare and those services are also                 claims and services to determine if any exclu-
   covered under this Plan, the Plan provider               sions or other limitations apply. Blue Shield may
   may recover the amount paid for the ser-                 use the services of physician consultants, peer
   vices under Medicare. This provision does                review committees of professional societies or
   not apply to Medicare Part D (outpatient                 hospitals and other consultants to evaluate
   prescription drug) benefits. This limitation             claims.
   for Medicare does not apply when the em-
   ployer is subject to the Medicare Secondary              General Provisions
   Payor Laws and the employer maintains:                   Grievance Process
                                                            Blue Shield of California has established a griev-
    a. an employer group health plan that cov-              ance procedure for receiving, resolving and
       ers                                                  tracking Members’ grievances with Blue Shield
       1) persons entitled to Medicare solely               of California.
          because of end-stage renal disease,
          and                                               For all services other than mental health
                                                            and substance abuse
       2) active employees or spouses or do-                The Member, a designated representative, or a
          mestic partners entitled to Medicare              provider on behalf of the Member, may contact
          by reason of age, and/or                          the Member Services Department by telephone,
                                                            letter or online to request a review of an initial
    b. a large group health plan as defined un-             determination concerning a claim or service.
       der the Medicare Secondary Payor laws                Members may contact the Plan at the telephone
       that covers persons entitled to Medicare             number as noted on the back cover of this
       by reason of disability.                             booklet. If the telephone inquiry to Member
                                                            Services does not resolve the question or issue
    This paragraph shall also apply to a Member
                                                            to the Member’s satisfaction, the Member may
    who becomes eligible for Medicare on the
                                                            request a grievance at that time, which the
    date that he received notice of his eligibility
                                                            Member Services Representative will initiate on
    for such enrollment.
                                                            the Member’s behalf.
2. Benefits provided by any other federal or
                                                            The Member, a designated representative, or a
   state governmental agency, or by any county
                                                            provider on behalf of the Member, may also ini-
   or other political subdivision, except that
                                                            tiate a grievance by submitting a letter or a com-

                                                       46
BASIC PLAN
pleted “Grievance Form.” The Member may re-               The MHSA will acknowledge receipt of a griev-
quest this form from Member Services. The                 ance within 5 calendar days. Grievances are re-
completed form should be submitted to Mem-                solved within 30 days. The grievance system
ber Services at the address as noted on the back          allows Members to file grievances for at least
cover of this booklet. The Member may also                180 days following any incident or action that is
submit the grievance online by visiting our web           the subject of the Member’s dissatisfaction. See
site at http://www.blueshieldca.com.                      the Member Services Department section for in-
                                                          formation on the expedited decision process.
Blue Shield will acknowledge receipt of a griev-
ance within 5 calendar days. Grievances are re-           External Independent Medical Review
solved within 30 days. The grievance system               If your grievance involves a claim or services for
allows Members to file grievances for at least            which coverage was denied by Blue Shield or by
180 days following any incident or action that is         a contracting provider in whole or in part on the
the subject of the Member’s dissatisfaction. See          grounds that the service is not medically neces-
the Member Services Department section for in-            sary or is experimental/investigational (including
formation on the expedited decision process.              the external review available under the Fried-
                                                          man-Knowles Experimental Treatment Act of
For all mental health and substance                       1996), you may choose to make a request to the
abuse services                                            Department of Managed Health Care to have
The Member, a designated representative, or a             the matter submitted to an independent agency
provider on behalf of the Member, may contact             for external review in accordance with California
the MHSA by telephone, letter or online to re-            law. You normally must first submit a grievance
quest a review of an initial determination con-           to Blue Shield and wait for at least 30 days be-
cerning a claim or service. Members may                   fore you request external review; however, if
contact the MHSA at the telephone number as               your matter would qualify for an expedited deci-
noted below. If the telephone inquiry to the              sion as described in the Member Services De-
MHSA’s Customer Service Department does                   partment section or involves a determination
not resolve the question or issue to the Mem-             that the requested service is experimen-
ber’s satisfaction, the Member may request a              tal/investigational, you may immediately request
grievance at that time, which the Customer Ser-           an external review following receipt of notice of
vice Representative will initiate on the Member’s         denial. You may initiate this review by complet-
behalf.                                                   ing an application for external review, a copy of
                                                          which can be obtained by contacting Member
The Member, a designated representative, or a             Services. The Department of Managed Health
provider on behalf of the Member, may also ini-           Care will review the application and, if the re-
tiate a grievance by submitting a letter or a com-        quest qualifies for external review, will select an
pleted “Grievance Form.” The Member may                   external review agency and have your records
request this form from the MHSA’s Customer                submitted to a qualified specialist for an inde-
Service Department. If the Member wishes, the             pendent determination of whether the care is
MHSA’s Customer Service staff will assist in              medically necessary. You may choose to submit
completing the Grievance Form. Completed                  additional records to the external review agency
grievance forms must be mailed to the MHSA at             for review. There is no cost to you for this ex-
the address provided below. The Member may                ternal review. You and your physician will re-
also submit the grievance to the MHSA online              ceive copies of the opinions of the external
by visiting http://www.blueshieldca.com.                  review agency. The decision of the external re-
                                                          view agency is binding on Blue Shield; if the ex-
                1-877-263-9952                            ternal reviewer determines that the service is
    U.S. Behavioral Health Plan, California               medically necessary, Blue Shield will promptly
           Attn: Customer Service                         arrange for the service to be provided or the
              P. O. Box 880609                            claim in dispute to be paid. This external review
            San Diego, CA 92168                           process is in addition to any other procedures or

                                                     47
BASIC PLAN
remedies available to you and is completely vol-           5. Disputed Health Care Service Issue. A
untary on your part; you are not obligated to re-             disputed health care service issue concerns
quest external review. However, failure to                    any health care service eligible for coverage
participate in external review may cause you to               and payment under this Evidence of Cover-
give up any statutory right to pursue legal action            age booklet that has been denied, modified,
against Blue Shield regarding the disputed ser-               or delayed in whole or in part due to a find-
vice. For more information regarding the exter-               ing that the service is not medically neces-
nal review process, or to request an application              sary. A decision regarding a disputed health
form, please contact Member Services.                         care service relates to the practice of medi-
                                                              cine and is not a coverage issue, and in-
Appeal Procedure Following Disposition                        cludes decisions as to whether a particular
of Plan Grievance Procedure                                   service is experimental or investigational.
If no resolution of your complaint is achieved
by the internal grievance process described                    If you are dissatisfied with the outcome of
above, you have several options depending on                   Blue Shield’s internal grievance process or if
the nature of your complaint.                                  you have been in the process for 30 days or
                                                               more, you may request an independent
1. Eligibility Issues. Refer these matters di-                 medical review from the Department of
   rectly to CalPERS. Contact CalPERS Office                   Managed Health Care.
   of Employer and Member Health Services
   at P.O. Box 942714, Sacramento, CA                          If you are dissatisfied with the outcome of
   94229-2714, Fax (916) 795-1277, or tele-                    the independent medical review process,
   phone CalPERS Customer Service and                          you may request an administrative review
   Education Division at 1-888 CalPERS (or                     before the CalPERS Board of Administra-
   888-225-7377), TTY 1-800-735-2929; (916)                    tion, or you may proceed to court.
   795-3240.
                                                           CalPERS Administrative Appeal Process
2. Coverage Issues. A coverage issue con-                  Only issues of eligibility and coverage issues
   cerns the denial or approval of health care             which concern the denial or approval of health
   services substantially based on a finding that          care services substantially based on a finding
   the provision of a particular service is in-            that the provision of a particular service is in-
   cluded or excluded as a covered benefit un-             cluded or excluded as a covered benefit under
   der this Evidence of Coverage booklet. It               this Evidence of Coverage booklet may be ap-
   does not include a plan or contracting pro-             pealed directly to CalPERS.
   vider decision regarding a disputed health
   care service.                                           CalPERS staff will conduct an administrative
                                                           review upon your appeal of Blue Shield’s denial
    If you are dissatisfied with the outcome of            of coverage or the denial of a disputed health
    Blue Shield’s internal grievance process or if         care issue by the Department of Managed
    you have been in the process for 30 days or            Health Care. However, your written appeal must
    more, you may request review by the De-                be submitted to CalPERS within 30 days of the
    partment of Managed Health Care, or you                postmark date of Blue Shield’s letter of denial or
    may request an administrative review before            the Department of Managed Health Care’s de-
    the CalPERS Board of Administration, or                termination of findings.
    you may choose Small Claims Court, if your
    coverage dispute is within the jurisdictional          If the dispute remains unresolved during the
    limits of Small Claims Court.                          administrative review process, the matter may
                                                           then proceed to an administrative hearing. Dur-
3. Malpractice. You must proceed directly to court.        ing the hearing, evidence and testimony will be
                                                           presented to an Administrative Law Judge.
4. Bad Faith. You must proceed directly to court.


                                                      48
BASIC PLAN
To file for an administrative review, contact             ployer and Member Health Services, P.O. Box
CalPERS Office of Employer and Member                     942714, Sacramento, CA 94229-2714.
Health Services, P.O. Box 942714, Sacramento,
CA 94229-2714, Fax (916) 795-1277, or tele-               Alternate Arrangements
phone CalPERS Customer Service and Educa-                 Blue Shield will make a reasonable effort to se-
tion Division, 1-888 CalPERS (or 888-225-                 cure alternate arrangements for the provision of
7377), TTY 1-800-735-2929; (916) 795-3240.                care by another Plan provider without additional
                                                          expense to you in the event a Plan provider’s
Department of Managed Health Care                         contract is terminated, or a Plan provider is un-
Review                                                    able or unwilling to provide care to you.
The California Department of Managed Health
Care is responsible for regulating health care            If such alternate arrangements are not made
service plans. If you have a grievance against            available, or are not deemed satisfactory to the
your health plan, you should first telephone              Board, then Blue Shield will provide all services
your health plan at 1-800-334-5847 and use your           and/or benefits of the Agreement to you on a
health plan’s grievance process before contact-           fee-for-service basis (less any applicable copay-
ing the Department. Utilizing this grievance              ments), and the limitation contained herein with
procedure does not prohibit any potential legal           respect to use of a Plan provider shall be of no
rights or remedies that may be available to you.          force or effect.
If you need help with a grievance involving an
emergency, a grievance that has not been satis-           Such fee-for-service arrangements shall continue
factorily resolved by your health plan, or a              until any affected treatment plan has been com-
grievance that has remained unresolved for                pleted or until such time as you agree to obtain
more than 30 days, you may call the Department            services from another Plan provider, your en-
for assistance. You may also be eligible for an           rollment is terminated, or your enrollment is
Independent Medical Review (IMR). If you are              transferred to another plan administered by the
eligible for IMR, the IMR process will provide            Board, whichever occurs first. In no case, how-
an impartial review of medical decisions made             ever, will such fee-for-service arrangements con-
by a health plan related to the medical necessity         tinue beyond the term of the Plan, unless the
of a proposed service or treatment, coverage de-          Extension of Benefits provision applies to you.
cisions for treatments that are experimental or
investigational in nature and payment disputes            Physician-Patient or Plan-Member
for emergency or urgent medical services. The             Relationship
Department also has a toll-free telephone num-            In the event that Blue Shield of California shall
ber (1-888-HMO-2219) and a TDD line (1-877-               be unable to establish satisfactory physician-
688-9891) for the hearing and speech impaired.            patient or plan-member relationship with any
The          Department’s        Web         site         member, after reasonable efforts to do so, then
(http://www.hmohelp.ca.gov) has complaint                 Blue Shield may either submit the matter for
forms, IMR application forms and instructions             consideration under Blue Shield's grievance pro-
online.                                                   cedures or submit the matter for consideration
                                                          by the Chief Executive Officer of CalPERS. In
In the event that Blue Shield should cancel or            any event, if it is determined that a satisfactory
refuse to renew enrollment for you or your de-            physician-patient or plan-member relationship
pendents and you feel that such action was due            cannot be maintained, then the member shall be
to health or utilization of benefits, you or your         provided with the opportunity to change en-
dependents may request a review by the De-                rollment to another plan.
partment of Managed Health Care Director.

Matters of eligibility should be referred directly
to CalPERS - contact CalPERS Office of Em-


                                                     49
BASIC PLAN
Termination of Group Membership -                         Code. If the Member does not access the
Continuation of Coverage                                  change of enrollment procedure, Blue Shield
Termination of Benefits                                   will undertake reasonable efforts to make a Plan
Coverage for you or your dependents terminates            physician available to the Member with whom a
at 12:01 a.m. Pacific Time on the earliest of             satisfactory relationship may be developed.
these dates: (1) the date the group Agreement is
                                                          In the event any Member believes that his or her
discontinued, (2) the last day of the month in
                                                          benefits under this Agreement have been termi-
which the subscriber’s employment terminates,
                                                          nated because of his or her health status or
unless a different date has been agreed to be-
                                                          health requirements, the Member may seek from
tween Blue Shield and your employer, (3) the
                                                          the Department of Managed Health Care, re-
end of the period for which the premium is
                                                          view of the termination as provided in Califor-
paid, or (4) on the last day of the month in
                                                          nia Health & Safety Code Section 1365(b).
which you or your dependents become ineligi-
ble. A spouse also becomes ineligible following
                                                          Reinstatement
legal separation from the subscriber, entry of a
final decree of divorce, annulment or dissolution         If you cancel or your coverage is terminated, re-
of marriage from the subscriber. A domestic               fer to the CalPERS “Health Program Guide.”
partner becomes ineligible upon termination of
the domestic partnership.                                 Cancellation
                                                          No benefits will be provided for services ren-
Except as specifically provided under the Exten-          dered after the effective date of cancellation, ex-
sion of Benefits and COBRA provisions, there              cept as specifically provided under the
is no right to receive benefits for services pro-         Individual Conversion Plan, Guaranteed Issue
vided following termination of this group                 Individual Coverage, Extension of Benefits, and
Agreement.                                                COBRA provisions in this booklet.

If you cease work because of retirement, disabil-         The group Agreement also may be cancelled by
ity, leave of absence, temporary layoff or termi-         CalPERS at any time provided written notice is
nation, see your employer about possibly                  given to Blue Shield to become effective upon
continuing group coverage. Also, see the Indi-            receipt, or on a later date as may be specified on
vidual Conversion Plan and COBRA and/or                   the notice.
Cal-COBRA provisions described in this book-
let for information on continuation of coverage.          Individual Conversion Plan
                                                          Regardless of age, physical condition or em-
If the subscriber no longer lives or works in the         ployment status, you may continue Blue Shield
Plan service area, coverage will be terminated            protection when you retire, leave the job or be-
for him and all his dependents. If a dependent            come ineligible for group coverage by applying
no longer lives or works in the Plan service area,        for a transfer to an individual conversion plan
then that dependent's coverage will be termi-             then being issued by Blue Shield.
nated. (Special arrangements may be available
for dependents who are full-time students or do           An application and first dues payment for the
not live in the subscriber's home. Please contact         conversion plan and the first month’s premium
the Member Services Department to request a               must be received by Blue Shield within 63 days
brochure which explains these arrangements.)              of the date of termination of your Blue Shield
                                                          group coverage. However, if the Blue Shield
If the relationship between a Plan physician and          group Agreement is terminated or your em-
a Member is unsatisfactory, or if the relationship        ployer withdraws from participation in the Pub-
between Blue Shield and a Member is unsatis-              lic Employees’ Medical and Hospital Care Act,
factory, then the Member may submit the mat-              transfer to the individual conversion plan will
ter to CalPERS under the change of enrollment             not be permitted. You will not be permitted to
procedure in Section 22841 of the Government              transfer to the individual conversion plan, and

                                                     50
BASIC PLAN
coverage under the individual conversion plan               • Your most recent coverage must have
will end, if you failed to continue enrollment or             been group coverage (COBRA and Cal-
to make contributions during continuation of                  COBRA are considered group coverage
enrollment in a non-pay status according to the               for these purposes);
Public Employees’ Medical and Hospital Care                 • You must have elected and exhausted all
Act Regulations.                                              COBRA and/or Cal-COBRA coverage
                                                              that is available to you;
A conversion plan is also available to:                     • You must not be eligible for nor have
                                                              any other health insurance coverage, in-
  • Dependents, if the subscriber dies;                       cluding a group health plan, Medicare or
  • Dependents who marry or exceed the                        Medi-Cal;
    maximum age for dependent coverage                      • You must make application to Blue
    under the group plan;                                     Shield for guaranteed issue coverage
  • Dependents, if the subscriber enters                      within 63 days of the date of termination
    military service;                                         from the group plan.
  • Spouse or domestic partner of a sub-
    scriber if their marriage or domestic                 If you elect conversion coverage, continuation
    partnership has terminated;                           of group coverage after COBRA and/or Cal-
  • Dependents, when continuation of cov-                 COBRA, or other Blue Shield individual plans,
    erage under COBRA and/or Cal-                         you will waive your right to this guaranteed issue
    COBRA expires, or is terminated.                      coverage. For more information, contact a Blue
                                                          Shield Member Services representative at the
When a dependent reaches the limiting age for             telephone number noted on your ID Card.
coverage as a dependent, or if a dependent be-
comes ineligible for any of the other reasons             Extension of Benefits
given above, it is your responsibility to inform          If a person becomes totally disabled while val-
Blue Shield. Upon receiving notification, Blue            idly covered under this Plan and continues to be
Shield will offer such dependent an individual            totally disabled on the date group coverage ter-
conversion plan for purposes of continuous                minates, Blue Shield will extend the benefits of
coverage.                                                 this Plan, subject to all limitations and restric-
                                                          tions, for covered services and supplies directly
Guaranteed Issue Individual Coverage                      related to the condition, illness or injury causing
Under the Health Insurance Portability and Ac-            such total disability until the first to occur of the
countability Act of 1996 (HIPAA) and under                following: (1) the date the covered person is no
California law, you may be entitled to apply for          longer totally disabled, (2) 12:01 a.m. on the day
certain of Blue Shield’s individual health plans          following a period of 12 months from the date
on a guaranteed issue basis (which means that             group coverage terminated, (3) the date on
you will not be rejected for underwriting reasons         which the covered person’s maximum benefits
if you meet the other eligibility requirements,           are reached, (4) the date on which a replacement
you live or work in Blue Shield’s service area,           carrier provides coverage to the person without
and you agree to pay all required dues). You may          limitation as to the totally disabling condition.
also be eligible to purchase similar coverage on a
guaranteed issue basis from any other health              No extension will be granted unless Blue Shield
plan that sells individual coverage for hospital,         receives written certification by a Plan physician
medical or surgical benefits. Not all Blue Shield         of such total disability within 90 days of the date
individual plans are available on a guaranteed is-        on which coverage was terminated, and thereaf-
sue basis under HIPAA. To be eligible, you                ter at such reasonable intervals as determined by
must meet the following requirements:                     Blue Shield.

  • You must have at least 18 or more
    months of creditable coverage;

                                                     51
BASIC PLAN
COBRA and/or Cal-COBRA                                      Four “qualifying events” allow an active or re-
Please examine your options carefully before                tired employee’s enrolled family member(s) to
declining this coverage. You should be aware                elect the continuation coverage for up to 36
that companies selling individual health insur-             months. Children born to or placed for adop-
ance typically require a review of your medical             tion with the Member during a COBRA con-
history that could result in a higher premium or            tinuation period may be added as dependents,
you could be denied coverage entirely.                      provided the employer is properly notified of
                                                            the birth or placement for adoption, and such
COBRA                                                       children are enrolled within 30 days of the birth
If a Member is entitled to elect continuation of            or placement for adoption.
group coverage under the terms of the Consoli-
dated Omnibus Budget Reconciliation Act                     1. The employee’s or retiree’s death (and the
(COBRA) as amended, the following applies:                     surviving family member is not eligible for a
                                                               monthly survivor allowance from CalPERS).
The COBRA group continuation coverage is
provided through federal legislation and allows             2. Divorce or legal separation of the covered
an enrolled active or retired employee or his/her              employee or retiree from the employee’s or
enrolled family member who lose their regular                  retiree’s spouse or termination of the do-
group coverage because of certain “qualifying                  mestic partnership.
events” to elect continuation for 18, 29, or 36
months.                                                     3. A dependent child ceases to be a dependent
                                                               child.
An eligible active or retired employee or his/her
family member(s) is entitled to elect this cover-           4. The primary COBRA subscriber becomes
age provided an election is made within 60 days                entitled to Medicare.
of notification of eligibility and the required
premiums are paid. The benefits of the con-                 If elected, COBRA continuation coverage is ef-
tinuation coverage are identical to the group               fective on the date coverage under the group
plan and the cost of coverage shall be 102% of              plan terminates.
the applicable group premiums rate. No em-
                                                            The COBRA continuation coverage will remain
ployer contribution is available to cover the
                                                            in effect for the specified time, or until one of
premiums.
                                                            the following events terminates the coverage:
Two “qualifying events” allow enrollees to re-
                                                            1. The termination of all employer provided
quest the continuation coverage for 18 months.
                                                               group health plans, or
The Member's 18-month period may also be ex-
tended to 29 months if the Member was dis-
                                                            2. The enrollee fails to pay the required pre-
abled on or before the date of termination or
                                                               mium(s) on a timely basis, or
reduction in hours of employment, or is deter-
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.


                                                       52
BASIC PLAN
You will receive notice from your employer of             continue coverage under Cal-COBRA at least 90
your eligibility for COBRA continuation cover-            calendar days before their COBRA coverage will
age if your employment is terminated or your              end. The COBRA enrollee should contact Blue
hours are reduced.                                        Shield for more information about continuing
                                                          coverage. If the enrollee elects to apply for con-
Contact your (former) employing agency or                 tinuation of coverage under Cal-COBRA, the
CalPERS directly if you need more information             enrollee must notify Blue Shield at least 30 days
about your eligibility for COBRA group con-               before COBRA termination.
tinuation coverage.
                                                          Continuation of Group Coverage
Cal-COBRA                                                 After COBRA and/or Cal-COBRA
COBRA enrollees who became eligible for CO-               The following section only applies to enrollees
BRA coverage on or after January 1, 2003, and             who became eligible for continuation of group
who reach the 18-month or 29-month maxi-                  coverage after COBRA and/or Cal-COBRA
mum available under COBRA, may elect to con-              prior to January 1, 2005:
tinue coverage under Cal-COBRA for a
maximum period of 36 months from the date                 Certain former employees and dependent
the Member's continuation coverage began un-              spouses or dependent domestic partners (includ-
der COBRA. If elected, the Cal-COBRA cover-               ing a spouse who is divorced from the current
age will begin after the COBRA coverage ends.             employee/former employee and/or a spouse
                                                          who was married to the employee/former em-
COBRA enrollees must exhaust all the COBRA                ployee at the time of that employee/former em-
coverage to which they are entitled before they           ployee's death, or a domestic partner whose
can become eligible to continue coverage under            partnership with the current employee/former
Cal-COBRA.                                                employee has terminated and/or a domestic
                                                          partner who was in a domestic partner relation-
In no event will continuation of group coverage           ship with the employee/former employee at the
under COBRA, Cal-COBRA or a combination                   time of that employee/former employee’s
of COBRA and Cal-COBRA be extended for                    death) may be eligible to continue group cover-
more than 3 years from the date the qualifying            age beyond the date their COBRA and/or Cal-
event has occurred which originally entitled the          COBRA coverage ends. Blue Shield will offer
Member to continue group coverage under this              the extended coverage to former employees of
Plan.                                                     employers that are subject to the existing CO-
                                                          BRA or Cal-COBRA, and to the former em-
Monthly rates for Cal-COBRA coverage shall be             ployees’ dependent spouses (including a
110% of the applicable group monthly rates.               divorced or widowed spouse as defined above)
                                                          or dependent domestic partners (including sur-
Cal-COBRA enrollees must submit monthly
                                                          viving domestic partners or domestic partners
rates directly to Blue Shield. The initial monthly
                                                          whose partnership was terminated as defined
rates must be paid within 45 days of the date the
                                                          above). This coverage is subject to the following
Member provided written notification to the
                                                          conditions:
Plan of the election to continue coverage and be
sent to Blue Shield by first-class mail or other          1. The former employee worked for the em-
reliable means. The monthly rate payment must                ployer for the prior 5 years and was 60 years
equal an amount sufficient to pay any required               of age or older on the date his/her employ-
amounts that are due. Failure to submit the cor-             ment ended.
rect amount within the 45-day period will dis-
qualify the Member from continuation coverage.            2. The former employee was eligible for and
                                                             elected COBRA and/or Cal-COBRA for
Blue Shield of California is responsible for noti-           himself and his dependent spouse (a former
fying COBRA enrollees of their right to possibly             spouse, i.e. a divorced or widowed spouse as

                                                     53
BASIC PLAN
    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
Termination of Continuation Coverage After
                                                            illness, not later than 30 days after submit-
COBRA and/or Cal-COBRA
                                                            ting or filing a claim or legal action against
This coverage will end automatically on the ear-            the third party; and
liest of:
                                                         2. Agree to fully cooperate with Blue Shield,
1. The date the former employee, spouse, or                 the Member’s designated medical group,
   domestic partner or former spouse or for-                and the independent practice association to
   mer domestic partner reaches 65;                         execute any forms or documents needed to
                                                            assist them in exercising their equitable right

                                                    54
BASIC PLAN
    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 patient as a dependent of
of, any employment for salary, wage or profit if             a person whose date of birth (excluding year of
such injury or disease is covered by any workers’            birth) occurs earlier in a calendar year, shall de-
compensation law, occupational disease law or                termine its benefits before a plan which covers
similar legislation.                                         that person as a dependent of a person whose
                                                             date of birth (excluding year of birth) occurs
However, if Blue Shield provides payment for                 later in a calendar year. If either plan does not
such services it will be entitled to establish a lien        have the provisions of this paragraph regarding
upon such other benefits up to the reasonable                dependents, which results either in each plan de-
cash value of benefits provided by Blue Shield               termining its benefits before the other or in each
for the treatment of the injury or disease as re-            plan determining its benefits after the other, the
flected by the providers’ usual billed charges.              provisions of this paragraph shall not apply, and
                                                             the rule set forth in the plan which does not
Coordination of Benefits                                     have the provisions of this paragraph shall de-
When a person who is covered under this group                termine the order of benefits.
Plan is also covered under another group plan,
or selected group, or blanket disability insurance           1. In the case of a claim involving expenses for
contract, or any other contractual arrangement                  a dependent child whose parents are sepa-
or any portion of any such arrangement                          rated or divorced, plans covering the child


                                                        55
BASIC PLAN
    as a dependent shall determine their respec-           the primary plan has not paid within a reason-
    tive benefits in the following order: First,           able period of time, this Plan will provide the
    the plan of the parent with custody of the             benefits that would be due as if it were the pri-
    child; then, if that parent has remarried, the         mary plan, provided that the covered person:
    plan of the stepparent with custody of the             (1) assigns to Blue Shield the right to receive
    child; and finally the plan(s) of the parent(s)        benefits from the other plan the extent of the
    without custody of the child.                          difference between the value of the benefits
                                                           which Blue Shield actually provides and the
2. Notwithstanding 1. above, if there is a court           value of the benefits that Blue Shield would
   decree which otherwise establishes financial            have been obligated to provide as the secondary
   responsibility for the medical, dental or               plan, (2) agrees to cooperate fully with Blue
   other health care expenses of the child, then           Shield in obtaining payment of benefits from
   the plan which covers the child as a depend-            the other plan, and (3) allows Blue Shield to ob-
   ent of the parent with that financial respon-           tain confirmation from the other plan that the
   sibility shall determine its benefits before            benefits which are claimed have not previously
   any other plan which covers the child as a              been paid.
   dependent child.
                                                           If payments which should have been made un-
3. If the above rules do not apply, the plan               der this Plan in accordance with these provi-
   which has covered the patient for the longer            sions have been made by another Plan, Blue
   period of time shall determine its benefits             Shield may pay to the other Plan the amount
   first, provided that:                                   necessary to satisfy the intent of these provi-
                                                           sions. This amount shall be considered as bene-
    a. A plan covering a patient as a laid-off or          fits paid under this Plan. Blue Shield shall be
       retired employee, or as a dependent of              fully discharged from liability under this Plan to
       such an employee, shall determine its               the extent of these payments.
       benefits after any other plan covering
       that person as an employee, other than a            If payments have been made by Blue Shield in
       laid-off or retired employee, or such de-           excess of the maximum amount of payment
       pendent; and,                                       necessary to satisfy these provisions, Blue Shield
                                                           shall have the right to recover the excess from
    b. If either plan does not have a provision            any person or other entity to or with respect to
       regarding laid-off or retired employees,            whom such payments were made.
       which results in each plan determining its
       benefits after the other, then the provi-           Blue Shield may release to or obtain from any
       sions of a. above shall not apply.                  organization or person any information which
                                                           Blue Shield considers necessary for the purpose
If this Plan is the primary carrier with respect to
                                                           of determining the applicability of and imple-
a covered person, then this Plan will provide its
                                                           menting the terms of these provisions or any
benefits without reduction because of benefits
                                                           provisions of similar purpose of any other Plan.
available from any other plan.
                                                           Any person claiming benefits under this Plan
                                                           shall furnish Blue Shield with such information
When this Plan is secondary in the order of
                                                           as may be necessary to implement these provi-
payments, and Blue Shield is notified that there
                                                           sions.
is a dispute as to which plan is primary, or that




                                                      56
                                                                                                                              Table of Contents
                                                                                                                                                                   Page
Section 2 - Supplement to Original Medicare Plan
 Summary of Covered Services ........................................................................................................... 59
 Benefit Changes for Current Year .................................................................................................... 61
 Eligibility........................................................................................................................................................... 61
 Enrollment ....................................................................................................................................................... 62
 How to Use the Plan .................................................................................................................................. 62
   Choice of Physicians and Providers............................................................................................................. 62
   Payment of Providers ..................................................................................................................................... 62
   Selecting a Personal Physician....................................................................................................................... 62
   Role of the Medical Group or IPA .............................................................................................................. 63
   Changing Personal Physicians or Designated Medical Group or IPA ................................................... 63
   Continuity of Care by a Terminated Provider............................................................................................ 64
   Relationship With Your Personal Physician ............................................................................................... 64
   How to Receive Care...................................................................................................................................... 65
   Use of Personal Physician.............................................................................................................................. 65
   Obstetrical/Gynecological (OB/GYN) Physician Services..................................................................... 65
   Referral to Specialty Services and Second Medical Opinions .................................................................. 65
   Access+ Specialist........................................................................................................................................... 66
   Lifepath Advisers ............................................................................................................................................ 67
   Mental Health and Substance Abuse Services............................................................................................ 67
   Emergency Services ........................................................................................................................................ 69
   Urgent Services................................................................................................................................................ 69
   Inpatient, Home Health Care and Other Services..................................................................................... 71
   Liability of Member for Payment ................................................................................................................. 71
   Limitation of Liability..................................................................................................................................... 71
   Member Identification Card.......................................................................................................................... 72
   Member Services Department ...................................................................................................................... 72
 Rates for Supplement to Original Medicare Plan..................................................................... 73
   State Employees and Annuitants.................................................................................................................. 73
   Contracting Agency Employees and Annuitants ....................................................................................... 73
 Benefit Descriptions ................................................................................................................................. 74
   Hospital Services ............................................................................................................................................. 74
   Physician Services (Other Than for Mental Health and Substance Abuse Services) ........................... 75
   Preventive Health Services ............................................................................................................................ 76
   Diagnostic X-ray/Lab Services..................................................................................................................... 76
   Durable Medical Equipment, Prostheses and Orthoses and Other Services ........................................ 77
   Pregnancy and Maternity Care ...................................................................................................................... 78
   Family Planning and Infertility Services ...................................................................................................... 79
   Ambulance Services........................................................................................................................................ 79
   Emergency Services ........................................................................................................................................ 80
   Urgent Services................................................................................................................................................ 81
   Home Health Care Services, PKU-Related Formulas and Special Food Products, and Home Infusion Therapy. 82
   Physical and Occupational Therapy............................................................................................................. 83
   Speech Therapy ............................................................................................................................................... 83
   Skilled Nursing Facility Services ................................................................................................................... 83
   Hospice Program Services............................................................................................................................. 84
   Prescription Drugs.......................................................................................................................................... 86
   Inpatient Mental Health and Substance Abuse Services........................................................................... 91




                                                                                57
Table of Contents
                                                                                                                                                                    Page
  Benefit Descriptions, Continued
    Outpatient Mental Health and Substance Abuse Services ........................................................................92
    Medical Treatment of the Teeth, Gums, Jaw Joints or Jaw Bones..........................................................92
    Special Transplant Benefits ............................................................................................................................93
    Organ Transplant Benefits .............................................................................................................................94
    Diabetes Care ...................................................................................................................................................94
    Reconstructive Surgery ...................................................................................................................................94
    Clinical Trials for Cancer................................................................................................................................95
    Additional Services ..........................................................................................................................................96
  Exclusions and Limitations ...................................................................................................................97
    General Exclusions and Limitations.............................................................................................................97
    Medical Necessity Exclusion........................................................................................................................100
    Limitations for Duplicate Coverage............................................................................................................100
    Exception for Other Coverage....................................................................................................................100
    Claims and Services Review .........................................................................................................................101
  General Provisions ...................................................................................................................................101
    Grievance Process .........................................................................................................................................101
    Appeal Procedure Following Disposition of Plan Grievance Procedure .............................................102
    CalPERS Administrative Appeal Process ..................................................................................................103
    Department of Managed Health Care Review ..........................................................................................103
    Alternate Arrangements................................................................................................................................103
    Physician-Patient or Plan-Member Relationship ......................................................................................104
    Advance Directives........................................................................................................................................104
  Termination of Group Membership - Continuation of Coverage ..................................104
    Termination of Benefits................................................................................................................................104
    Reinstatement.................................................................................................................................................105
    Cancellation ....................................................................................................................................................105
    Extension of Benefits....................................................................................................................................105
    COBRA and/or Cal-COBRA......................................................................................................................105
  Payment by Third Parties .....................................................................................................................107
    Third Party Recovery Process and the Member’s Responsibility ..........................................................107
    Workers’ Compensation ...............................................................................................................................107
    Coordination of Benefits ..............................................................................................................................108
Section 3 - General Information for All Members ....................................................111
  Definitions ......................................................................................................................................................111
   Members Rights and Responsibilities.........................................................................................................117
   Public Policy Participation Procedure ........................................................................................................118
   Confidentiality of Medical Records and Personal Health Information.................................................119
   Access to Information ..................................................................................................................................119
   Non-Assignability ..........................................................................................................................................119
   Facilities...........................................................................................................................................................119
   Independent Contractors .............................................................................................................................120
   Access+ Satisfaction......................................................................................................................................120
   Web Site ..........................................................................................................................................................120
   Utilization Review Process...........................................................................................................................120
   Preventive Health Guidelines ......................................................................................................................121
  Service Area ..................................................................................................................................................126




                                                                                 58
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 & Preventive Health
    Office/Home Visits                                                    $10/visit
    Allergy Testing/Treatment                                             $10/visit
    Inpatient Hospital Visits                                            No Charge
    Surgery/Anesthesia                                                   No Charge
    Periodic Health Exam                                                  $10/visit
    Gynecological Exam                                                    $10/visit
         (including Pap smear and breast exam)
    Vision Screening                                                      $10/visit
    Hearing Exam/Testing                                                  $10/visit
    Immunization/Inoculation                                          $10/immunization
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 - waived if hospitalized or kept for
Emergency Care/Services                                 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




                                                   59
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
                                                         $5 generic, $15 brand name, $45 non-
                                                         Formulary/prescription – not to exceed a 30-
Prescription Drugs                                       day supply for short-term or acute illness.
                                                         $10 generic, $25 brand name, $75 non-
                                                         Formulary/prescription – not to exceed a 90-
                                                         day supply for mail order drugs which are taken
                                                         over long periods of time (maintenance drugs);
                                                         $1,000 out-of-pocket annual maximum.
Mental Health
  Inpatient                                                                    No Charge
    Outpatient                                           $20/visit - up to 20 visits per calendar year for
                                                         other than severe mental illnesses or serious
   The Member copayment for the initial visit to de-
                                                         emotional disturbances of a child.
   termine the condition and diagnosis of the Mem-
   ber (except for Access+ Specialist visits, which      $10/visit for severe mental illnesses or serious
   require a $30 copayment per visit) will be $10 per    emotional disturbances of a child.
   visit. Access+ Specialist visits will accrue toward
   the 20 visit per calendar year maximum.
Substance Abuse
   Inpatient (limited to acute medical detoxification                          No Charge
   only)
    Outpatient                                           $10/visit - up to 20 visits per calendar year.
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.




                                                   60
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Benefit Changes                                           and Member Health Services with a copy of
for Current Year                                          your Medicare card or Letter Of Entitlement
There are no benefit changes this year.                   with a letter to CalPERS requesting enrollment.

BENEFITS OF THIS PLAN ARE AVAIL-                          A Medicare prescription drug program, known
ABLE ONLY FOR SERVICES AND SUP-                           as Medicare Part D, became effective January 1,
PLIES FURNISHED DURING THE TERM                           2006. Blue Shield Supplement to Original Medi-
THE PLAN IS IN EFFECT AND WHILE                           care members do not need to enroll in Medicare
THE INDIVIDUAL CLAIMING BENEFITS                          Part D because your current Blue Shield pre-
IS ACTUALLY COVERED BY THE GROUP                          scription drug benefit as specified by CalPERS
AGREEMENT.                                                is superior in both benefit and cost.

IF BENEFITS ARE MODIFIED, THE RE-                         The Blue Shield Access+ HMO benefits will be
VISED BENEFITS (INCLUDING ANY RE-                         reduced by the benefits covered by both Medi-
DUCTION      IN    BENEFITS    OR                         care Part A (hospital benefits) and Medicare
ELIMINATION OF BENEFITS) APPLY TO                         Part B (professional benefits), but not for Medi-
SERVICES OR SUPPLIES FURNISHED ON                         care Part D (prescription drugs). The Blue Shield
OR AFTER THE EFFECTIVE DATE OF                            Access+ HMO will cover benefits only to the
MODIFICATION. THERE IS NO VESTED                          extent services are coordinated by your Personal
RIGHT TO RECEIVE THE BENEFITS OF                          Physician and authorized by the Blue Shield Ac-
THIS PLAN.                                                cess+ HMO. This Plan does not cover custodial
                                                          care. Benefits are provided for covered services
Eligibility                                               whether or not they are covered by Medicare. If
Information pertaining to your eligibility, en-           the covered services are also covered by Medi-
rollment, cancellation or termination of cover-           care, then the Plan providers who render those
age, conversion rights, etc. can be found in the          services will bill and seek payment directly from
CalPERS informational booklet “Health Pro-                Medicare. You are not responsible for the
gram Guide.” The booklet is prepared by                   amounts not paid by Medicare for covered ser-
CalPERS Office of Employer and Member                     vices, except for the copayment amounts set
Health Services in Sacramento. You can order              forth in this Evidence of Coverage.
this booklet using the postage-paid order card
included in the Open Enrollment mailing,                  Under the Public Employees’ Medical and Hos-
through      the     CalPERS        Web      site         pital Care Act (PEMHCA), if you are Medicare
(http://www.calpers.ca.gov),       by     calling         eligible and do not enroll in Medicare Parts A
CalPERS, or by contacting your Health Benefits            and B and a CalPERS Medicare health plan, you
Officer.                                                  and your enrolled dependents will be excluded
                                                          from coverage under the CalPERS program.
If you or any of your dependents are currently
eligible or become eligible for Medicare and you          If either you or your spouse is over the age of
are not an active employee, you may enroll in             65 and you are actively employed, neither you
the Blue Shield Access+ HMO Supplement to                 nor your spouse is eligible for Supplement to
Original Medicare Plan. You may also enroll in            Original Medicare Plan benefits (unless it is de-
the Access+ HMO Supplement to Original Medi-              termined that Medicare is the primary payor for
care Plan if it is determined for any other reason        you or your spouse under the Medicare Secondary
that Medicare is the primary payor for you or your        Payor laws).
spouse under the Medicare Secondary Payor laws
                                                          For answers to questions regarding Medicare,
(e.g., for end-stage renal disease). You are re-
                                                          contact your local Social Security office or call
quired to enroll in both Medicare Parts A and B
                                                          Medicare's toll-free number 1-800-633-4227.
to be eligible for Blue Shield Access+ HMO
                                                          You may also visit the Medicare Web site at
Supplement to Original Medicare Plan benefits
                                                          http://www.medicare.gov.
and to provide CalPERS Office of Employer

                                                     61
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
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 1-888 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
Benefits of this Plan become effective at 12:01         because your Personal Physician will:
a.m. Pacific Time on the eligibility date estab-
lished by CalPERS.                                       • Help you decide on actions to maintain
                                                           and improve your total health;
Enrollment                                               • Coordinate and direct all of your medical
Information pertaining to enrollment can be                care needs;
found in the CalPERS “Health Program                     • Authorize emergency services when ap-
Guide.” To enroll or make changes, active                  propriate;
members must submit a completed Health                   • Work with your medical group or IPA to
Benefit Enrollment Form (CalPERS HBD-12).                  arrange your referrals to specialty physi-
Retired members must submit a signed, written              cians, hospitals and all other health ser-
request or a completed Health Plan Change Re-              vices, including requesting any prior
quest Form for Retirees (CalPERS HBD-30). If               authorization you will need;
you need assistance in completing these forms,           • Prescribe those lab tests, x-rays and ser-
contact CalPERS Office of Employer and                     vices you require;
Member Health Services.                                  • If you request it, assist you in obtaining
                                                           prior approval from the Mental Health
How to Use the Plan                                        Services Administrator (MHSA) for
Choice of Physicians and Providers                         mental health and substance abuse ser-
PLEASE READ THE FOLLOWING IN-                              vices. See the Mental Health and Sub-
FORMATION SO YOU WILL KNOW                                 stance Abuse Services paragraphs in the
FROM WHOM OR WHAT GROUP OF                                 How to Use the Plan section for infor-
PROVIDERS HEALTH CARE MAY BE                               mation; and,
OBTAINED.                                                • Assist you in applying for admission into
                                                           a hospice program through a participat-
Payment of Providers                                       ing hospice agency when necessary.
Blue Shield generally contracts with groups of
physicians to provide services to Members. A            To ensure access to services, each Member must
fixed, monthly fee is paid to these groups of           select a Personal Physician who is located suffi-
physicians for each Member whose Personal               ciently close to the Member’s home or work ad-
Physician is in the group. This payment system,         dress to ensure reasonable access to care, as
capitation, includes incentives to the groups of        determined by Blue Shield. If you do not select
physicians to manage all services provided to           a Personal Physician at the time of enrollment,
                                                        the Plan will designate a Personal Physician for

                                                   62
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
you and you will be notified of the name of the             or hospitals within your designated medical
designated Personal Physician. This designation             group or IPA unless because of your health
will remain in effect until you notify the Plan of          condition, care is unavailable within the medical
your selection of a different Personal Physician.           group or IPA.

A Personal Physician must also be selected for a            Your designated medical group or IPA (or Blue
newborn or child placed for adoption, prefera-              Shield when noted on your identification card)
bly prior to birth or adoption, but always within           ensures that a full panel of specialists is available
31 days from the date of birth or placement for             to provide your health care needs and helps
adoption. The Personal Physician selected for               your Personal Physician manage the utilization
the month of birth must be in the same medical              of your health plan benefits by ensuring that re-
group or IPA as the mother’s Personal Physi-                ferrals are directed to providers who are con-
cian when the newborn is the natural child of               tracted with them. Medical groups or IPAs also
the mother. If the mother of the newborn is not             have admitting arrangements with hospitals con-
enrolled as a Member or if the child has been               tracted with Blue Shield in their area and some
placed with the subscriber for adoption, the                have special arrangements that designate a spe-
Personal Physician selected must be a physician             cific hospital as “in network.” Your designated
in the same medical group or IPA as the sub-                medical group or IPA works with your Personal
scriber. If you do not select a Personal Physician          Physician to authorize services and ensure that
within 31 days following the birth or placement             that service is performed by their in network
for adoption, the Plan will designate a Personal            provider.
Physician from the same medical group or IPA
as the natural mother or the subscriber. This               The name of your Personal Physician and your
designation will remain in effect for the first cal-        designated medical group or IPA (or, “Blue
endar month during which the birth or place-                Shield Administered”) is listed on your Access+
ment for adoption occurred. If you want to                  HMO identification card. The Blue Shield
change the Personal Physician for the child after           HMO Member Services Department can answer
the month of birth or placement for adoption,               any questions you may have about changing the
see the section below on Changing Personal                  medical group or IPA designated for your Per-
Physicians or Designated Medical Group or                   sonal Physician and whether the change would
IPA. If your child is ill during the first month of         affect your ability to receive services from a par-
coverage, be sure to read the information about             ticular specialist or hospital.
changing Personal Physicians during a course of
treatment or hospitalization.                               Changing Personal Physicians or
                                                            Designated Medical Group or IPA
Remember that if you want your child covered                You or your dependent may change Personal
beyond the 31 days from the date of birth or                Physicians or designated medical group or IPA
placement for adoption, you should contact                  by calling the Member Services Department at
CalPERS Office of Employer and Member                       1-800-334-5847. Some Personal Physicians are
Health Services and Blue Shield to add your                 affiliated with more than one medical group or
child to your coverage.                                     IPA. If you change to a medical group or IPA
                                                            with no affiliation to your Personal Physician,
Role of the Medical Group or IPA                            you must select a new Personal Physician affili-
Most Blue Shield Access+ HMO Personal Phy-                  ated with the new medical group or IPA and
sicians contract with medical groups or IPAs to             transition any specialty care you are receiving to
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

                                                       63
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
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-
tive date of your new medical group or IPA will           minal illness; or who are children from birth to
be the first of the month following discharge             36 months of age; or who have received au-
from the hospital, or when pregnant, following            thorization from a now-terminated provider for
the completion of post-partum care.                       surgery or another procedure as part of a docu-
                                                          mented course of treatment can request comple-
Additionally, changing your Personal Physician            tion of care in certain situations with a provider
or designated medical group or IPA during a               who is leaving the Blue Shield provider network.
course of treatment may interrupt the quality             Contact Member Services to receive information
and continuity of your health care. For this rea-         regarding eligibility criteria and the policy and
son, the effective date of your new Personal              procedure for requesting continuity of care from
Physician or designated medical group or IPA,             a terminated provider.
when requested during a course of treatment,
will be the first of the month following the date         Relationship With Your Personal
it is medically appropriate to transfer your care         Physician
to your new Personal Physician or designated              The physician-patient relationship you and your
medical group or IPA, as determined by the                Personal Physician establish is very important.
Plan.                                                     The best effort of your Personal Physician will
                                                          be used to ensure that all medically necessary
Exceptions must be approved by the Blue
                                                          and appropriate professional services are pro-
Shield Medical Director. For information about
                                                          vided to you in a manner compatible with your
approval for an exception to the above provi-
                                                          wishes. If your Personal Physician recommends
sion, please contact Member Services.
                                                          procedures or treatments which you refuse, or
If your Personal Physician discontinues partici-          you and your Personal Physician fail to establish
pation in the Plan, Blue Shield will notify you in        a satisfactory relationship, you may select a dif-
writing and designate a new Personal Physician            ferent Personal Physician. Member Services can
for you in case you need immediate medical                assist you with this selection.
care. You will also be given the opportunity to
                                                          Your Personal Physician will advise you if he be-
select a new Personal Physician of your own
                                                          lieves that there is no professionally acceptable
choice within 15 days of this notification. Your
                                                          alternative to a recommended treatment or pro-
selection must be approved by Blue Shield prior
                                                          cedure. If you continue to refuse to follow the
to receiving any services under the Plan. In the
                                                          recommended treatment or procedure, Member
event that your selection has not been approved
                                                          Services can assist you in the selection of an-
and an emergency arises, see I. Emergency Ser-
                                                          other Personal Physician.

                                                     64
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Repeated failures to establish a satisfactory rela-        If you have not selected a Personal Physician for
tionship with a Personal Physician may result in           any reason, you must contact Member Services
termination of your coverage, but only after you           at 1-800-334-5847, Monday through Friday, be-
have been given access to other available Per-             tween 7 a.m. and 7 p.m. to select a Personal
sonal Physicians and have been unsuccessful in             Physician to obtain benefits.
establishing a satisfactory relationship. Any such
termination will take place in accordance with             Obstetrical/Gynecological (OB/GYN)
written procedures established by Blue Shield              Physician Services
and only after written notice to the Member                A female Member may arrange for obstetrical
which describes the unacceptable conduct, pro-             and/or gynecological (OB/GYN) services by an
vides the Member with an opportunity to re-                obstetrician/gynecologist or a family practice
spond and warns the Member of the possibility              physician who is not her designated Personal
of termination.                                            Physician without obtaining a referral. However,
                                                           the obstetrician/gynecologist or family practice
How to Receive Care                                        physician must be in the same medical group or
Use of Personal Physician                                  IPA as her Personal Physician.
At the time of enrollment, you will choose a
Personal Physician who will coordinate all cov-            Obstetrical and gynecological services are de-
ered services. You must contact your Personal              fined as:
Physician for all health care needs, including
preventive services, routine health problems,                • Physician services related to prenatal,
consultations with Plan specialists (except as                 perinatal and postnatal (pregnancy) care,
provided under Obstetrical/Gynecological                     • Physician services provided to diagnose
(OB/GYN) Physician Services, Access+ Spe-                      and treat disorders of the female repro-
cialist, and Mental Health and Substance Abuse                 ductive system and genitalia,
Services), admission into a hospice program                  • Physician services for treatment of dis-
through a participating hospice agency, emer-                  orders of the breast,
gency services, urgent services and for hospitali-           • Routine annual gynecological examina-
zation. The Personal Physician is responsible for              tions/annual well-woman examinations.
providing primary care and coordinating or ar-
ranging for referral to other necessary health             It is important to note that services by an obste-
care services and requesting any needed prior              trician/gynecologist or a family practice physi-
authorization. You should cancel any scheduled             cian outside of the Personal Physician’s medical
appointments at least 24 hours in advance. This            group or IPA without authorization will not be
policy applies to appointments with or arranged            covered under this Plan. Before making the ap-
by your Personal Physician or the Mental Health            pointment, the Member should call the Member
Services Administrator (MHSA) and self-                    Services Department at 1-800-334-5847 to con-
arranged appointments to an Access+ Specialist             firm that the obstetrician/gynecologist or family
or for OB/GYN services. Because your physi-                practice physician is in the same medical group
cian has set aside time for your appointments in           or IPA as her Personal Physician.
a busy schedule, you need to notify the office
within 24 hours if you are unable to keep the              The OB/GYN physician services are separate
appointment. That will allow the office staff to           from the Access+ Specialist feature described
offer that time slot to another patient who needs          below.
to see the physician. Some offices may advise
you that a fee (not to exceed your copayment)              Referral to Specialty Services and
will be charged for missed appointments unless             Second Medical Opinions
you give 24-hour advance notice or missed the              Although self-referrals to Plan specialists are al-
appointment because of an emergency situation.             lowed through the Access+ Specialist feature
                                                           described below, Blue Shield encourages you to
                                                           receive specialty services through a referral from

                                                      65
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
your Personal Physician. The Personal Physician           Department at the number listed on the back
is responsible for coordinating all of your health        cover of this booklet.
care needs and can best direct you for required
specialty services. Your Personal Physician will          If your Personal Physician belongs to a medical
generally refer you to a Plan specialist or Plan          group or IPA that participates as an Access+
non-physician health care practitioner in the             Provider, you may also arrange a second opinion
same medical group or IPA as your Personal                visit with another physician in the same medical
Physician, but you can be referred outside the            group or IPA without a referral, subject to the
medical group or IPA if the type of specialist or         limitations described in the Access+ Specialist
non-physician health care practitioner needed is          paragraphs later in this section.
not available within your Personal Physician’s
medical group or IPA. Your Personal Physician             To obtain referral for specialty services, includ-
will request any necessary prior authorization            ing lab and x-ray, you must first contact your
from your medical group or IPA. For mental                Personal Physician. If the Personal Physician de-
health care and substance abuse benefits, see the         termines that specialty services are medically
Mental Health and Substance Abuse Services                necessary, the physician will complete a referral
paragraphs in the How to Use the Plan section             form and request necessary authorization. Your
for information regarding how to access care.             Personal Physician will designate the Plan pro-
The Plan specialist or Plan non-physician health          vider from whom you will receive services.
care practitioner will provide a complete report          When no Plan provider is available to perform
to your Personal Physician so that your medical           the needed service, the Personal Physician will
record is complete.                                       refer you to a non-Plan provider after obtaining
                                                          authorization. This authorization procedure is
If there is a question about your diagnosis, plan         handled for you by your Personal Physician.
of care, or recommended treatment, including
surgery, or if additional information concerning          In certain situations where the Member's medi-
your condition would be helpful in determining            cal condition or disease is life-threatening, de-
the diagnosis and the most appropriate plan of            generative, or disabling and requires specialized
treatment, or if the current treatment plan is not        medical care over a prolonged period of time,
improving your medical condition, you may ask             the Personal Physician may make a standing re-
your Personal Physician to refer you to another           ferral (more than one visit) to an appropriate
physician for a second medical opinion. The               specialist.
second opinion will be provided on an expe-
dited basis, where appropriate. If you are re-            Referral by a Personal Physician does not guar-
questing a second opinion about care you                  antee coverage for referral services. The eligibil-
received from your Personal Physician, the sec-           ity provisions, exclusions and limitations will
ond opinion will be provided by a physician               apply.
within the same medical group or IPA as your
Personal Physician. If you are requesting a sec-          Access+ Specialist
ond opinion about care received from a special-           You may arrange an office visit with a Plan spe-
ist, the second opinion may be provided by any            cialist in the same medical group or IPA as your
Plan specialist of the same or equivalent spe-            Personal Physician without a referral from your
cialty. All second opinion consultations must be          Personal Physician, subject to the limitations de-
authorized. Your Personal Physician may also              scribed below. Access+ Specialist office visits
decide to offer such a referral even if you do not        are available only to Members whose Personal
request it. State law requires that health plans          Physicians belong to a medical group or IPA
disclose to Members, upon request, the time-              that participates as an Access+ Provider. Refer
lines for responding to a request for a second            to the HMO Physician and Hospital Directory
medical opinion. To request a copy of these               or call Blue Shield Member Services at 1-800-
timelines, you may call the Member Services               334-5847 to determine whether a medical group
                                                          or IPA is an Access+ Provider. You will be re-


                                                     66
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
sponsible for a $30 copayment for each Access+             • Any diagnostic imaging including CT,
Specialist visit. This copayment is in addition to           MRI, or bone density measurement;
any copayments that you may incur for specific             • Injectables, chemotherapy or other infu-
benefits as described in the Summary of Bene-                sion drugs, other than vaccines and anti-
fits. Each follow-up office visit with the Plan              biotics;
specialist which is not referred or authorized by          • Infertility services;
your Personal Physician is a separate Access+              • Emergency services;
Specialist visit and requires a separate $30 co-           • Urgent services;
payment.                                                   • Inpatient services, or any services which
                                                             result in a facility charge, except for rou-
You should cancel any scheduled Access+ Spe-                 tine x-ray and laboratory services;
cialist appointment at least 24 hours in advance.
                                                           • Services for which the medical group or
Unless you give 24-hour advance notice or miss
                                                             IPA routinely allows the Member to self-
the appointment because of an emergency situa-
                                                             refer without authorization from the
tion, the physician’s office may charge you a fee
                                                             Personal Physician;
as much as the Access+ Specialist copayment.
                                                           • OB/GYN services by an obstetrician/
For Access+ Specialist visits for mental health              gynecologist or a family practice physi-
and substance abuse services, see the following              cian within the same medical group or
Mental Health and Substance Abuse Services                   IPA as the Personal Physician;
paragraphs.                                                • Internet-based consultations.

The Access+ Specialist visit includes:                    Lifepath Advisers
                                                          Blue Shield of California's Lifepath Advisers
 • An examination or other consultation                   provides Members with no charge, confidential,
   provided to you by a medical group Plan                unlimited telephone support for information,
   specialist without referral from your Per-             consultations, and referrals for health and psy-
   sonal Physician;                                       chosocial issues. Members may obtain these ser-
 • Conventional x-rays such as chest x-rays,              vices by calling 1-866-543-3728, a 24-hour, toll-
   abdominal flat plates, and x-rays of                   free telephone number. There is no charge for
   bones to rule out the possibility of frac-             these services.
   ture (but does not include any diagnostic
   imaging such as CT, MRI, or bone den-                  Lifepath Advisers includes a nurse support (see
   sity measurement);                                     C. Preventive Health Services) and a psychoso-
 • Laboratory services;                                   cial support feature (see the following section
 • Diagnostic or treatment procedures                     Mental Health and Substance Abuse Services).
   which a Plan specialist would regularly
   provide under a referral from the Per-                 Mental Health and Substance Abuse
   sonal Physician.                                       Services
                                                          Blue Shield of California has contracted with a
An Access+ Specialist visit does not include:             Mental Health Services Administrator (MHSA)
                                                          to underwrite and deliver all mental health and
 • Any services which are not covered or                  substance abuse services through a unique net-
   which are not medically necessary;                     work of mental health Participating Providers.
 • Services provided by a non-Access+                     (See Mental Health Services Administrator un-
   Provider (such as podiatry and physical                der the Definitions section for more informa-
   therapy), except for the x-ray and labora-             tion.) All non-emergency mental health and
   tory services described above;                         substance abuse services, except for Access+
 • Allergy testing;                                       Specialist visits, must be arranged through the
 • Endoscopic procedures;                                 MHSA. Members do not need to arrange for
                                                          mental health and substance abuse services


                                                     67
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
through their Personal Physician. (See 1. Prior                tion not to exceed 72 hours from re-
Authorization paragraphs below.)                               ceipt of the request;
                                                             • for other services, within 5 business
All mental health and substance abuse services,                days from receipt of the request. The
except for emergency or urgent services, must                  treating provider will be notified of the
be provided by a MHSA Participating Provider.                  decision within 24 hours followed by
MHSA Participating Providers are indicated in                  written notice to the provider and
the Blue Shield of California Behavioral Health                Member within 2 business days of the
Provider Directory. Members may contact the                    decision.
MHSA directly for information on, and to select
a MHSA Participating Provider by calling 1-866-           2. Access+ Specialist Visits for Mental Health
505-3409. Your Personal Physician may also                   and Substance Abuse Services
contact the MHSA to obtain information re-
garding MHSA Participating Providers for you.                The Access+ Specialist feature is available
                                                             for all mental health and substance abuse
Non-emergency mental health and substance                    services except for psychological testing and
abuse services received from a provider who                  written evaluation which are not covered
does not participate in the MHSA Participating               under this benefit.
Provider network will not be covered and all
charges for these services will be the Member’s              The Member may arrange for an Access+
responsibility.                                              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
   Failure to receive prior authorization for
   mental health and substance abuse services                Notwithstanding the benefits provided un-
   as described, except for emergency and ur-                der R. Outpatient Mental Health and Sub-
   gent services, will result in the Member be-              stance Abuse Services, the Member also
   ing totally responsible for all costs for these           may call 1-866-543-3728 on an unlimited,
   services.                                                 24-hour basis for confidential psychosocial
                                                             support services available through Lifepath
   Note: The MHSA will render a decision on                  Advisers. Professional counselors will pro-
   all requests for prior authorization of ser-              vide support through assessment, referrals
   vices as follows:                                         and 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


                                                     68
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
   maximum of three no charge, face-to-face                    Contact your Personal Physician no later
   visits per episode of major life events. An                 than 24 hours after the onset of the emer-
   episode shall mean a single event, or multi-                gency.
   ple events which occur within a 6-month
   period and are determined by a counselor to             Non-Life Threatening
   be related. Major life events include work-                 Consult your Personal Physician, anytime
   related problems, marital and relationship                  day or night, regardless of where you are
   issues, family problems, emotional and per-                 prior to receiving medical care.
   sonal issues and death and dying issues.
   These visits will not accrue to the benefit             Follow-Up Care
   maximums that are applicable to mental                      Follow-up care, which is any care provided
   health and substance abuse services.                        after the initial emergency room visit, must
                                                               be provided or authorized by your Personal
   In the event that the services required of a                Physician.
   Member are most appropriately provided by
   a psychiatrist or the condition is not likely to        For a complete description of the Emergency
   be resolved in a brief treatment regimen, the           Services benefit and applicable copayments, see
   Member will be referred to the MHSA in-                 I. Emergency Services in the Benefit Descrip-
   take line to access his mental health and               tions section.
   substance abuse services which are de-
   scribed under R. Outpatient Mental Health               Urgent Services
   and Substance Abuse Services.                           The Blue Shield Access+ HMO provides cover-
                                                           age for you and your family for your urgent ser-
Emergency Services                                         vice needs when you or your family are
What is an Emergency?                                      temporarily traveling outside of your Personal
An emergency means an unexpected medical                   Physician service area.
condition manifesting itself by acute symptoms
of sufficient severity (including severe pain)             Urgent services are defined in Section 3, under
such that a layperson who possesses an average             Definitions. Out-of-area follow-up care is de-
knowledge of health and medicine could rea-                fined in Section 3, under Definitions.
sonably assume that the absence of immediate
medical attention could be expected to result in           Outside of California or the United States
any of the following: (1) placing the Member’s             The Blue Shield Access+ HMO provides cover-
health in serious jeopardy, (2) serious impair-            age for you and your family for your urgent ser-
ment to bodily functions, (3) serious dysfunc-             vice needs when you or your family are
tion of any bodily organ or part. If you receive           temporarily traveling outside of California. You
non-authorized services in a situation that Blue           can receive urgent care services from any pro-
Shield determines was not a situation in which a           vider; however, using the BlueCard® Program,
reasonable person would believe that an emer-              described below, can be more cost-effective and
gency condition existed, you will be responsible           eliminate the need for you to pay for the services
for the costs of those services.                           when they are rendered and submit a claim for re-
                                                           imbursement.
Members who reasonably believe that they have
an emergency medical or mental health condi-               Through the BlueCard Program, you can access
tion which requires an emergency response are              urgent care services across the country and
encouraged to appropriately use the “911”                  around the world. While traveling within the
emergency response system where available.                 United States, you can locate a BlueCard Pro-
                                                           gram participating provider any time by calling
What to do in case of Emergency:                           1-800-810-BLUE (2583) or going on-line at
Life Threatening                                           www.bcbs.com and selecting the “Find a Doc-
   Obtain care immediately.                                tor or Hospital” tab. If you are traveling outside

                                                      69
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
of the United States, you can call 1-804-673-1177          actual price paid than will the estimated price.
collect 24 hours a day to locate a BlueCard                The negotiated price will also be adjusted in the
Worldwide® Network provider.                               future to correct for over- or underestimation of
                                                           past prices. However, the amount you pay is
Out-of-area follow-up care is covered and may              considered a final price.
be received through the BlueCard Program par-
ticipating provider network or from any pro-               Statutes in a small number of states may require
vider. However, authorization by Blue Shield is            the local Blue Cross and/or Blue Shield plan to
required for more than two out-of-area follow-             use a basis for calculating Member liability for
up care outpatient visits or for care that involves        covered services that does not reflect the entire
a surgical or other procedure or inpatient stay.           savings realized, or expected to be realized, on a
The Blue Shield Access+ HMO may direct the                 particular claim or to add a surcharge. Should
patient to receive the additional follow-up ser-           any state statutes mandate Member liability cal-
vices from the Personal Physician.                         culation methods that differ from the usual
                                                           BlueCard Program method noted above or re-
If services are not received from a BlueCard               quire a surcharge, Blue Shield of California
Program participating provider, you may be re-             would then calculate your liability for any cov-
quired to pay the provider for the entire cost of          ered health care services in accordance with the
the service and submit a claim to the Blue Shield          applicable state statute in effect at the time you
Access+ HMO. Claims for urgent services and                received your care.
out-of-area follow-up care rendered outside of
California and not provided by a BlueCard Pro-             For any other providers, the amount you pay, if
gram participating provider will be reviewed ret-          not subject to a flat dollar copayment, is calcu-
rospectively for coverage.                                 lated on the provider’s billed charges for your
                                                           covered services.
Under the BlueCard Program, when you obtain
health care services outside of California, the            Within California
amount you pay, if not subject to a flat dollar            If you are temporarily traveling within Califor-
copayment, is calculated on the lower of:                  nia, but are outside of your Personal Physician
                                                           service area, if possible you should call Blue
1. The billed charges for your covered services,           Shield Member Services at 1-800-334-5847 for
   or                                                      assistance in receiving urgent services through a
                                                           Blue Shield of California Plan provider. You may
2. The negotiated price that the local Blue                also locate a Plan provider by visiting our web site
   Cross and/or Blue Shield plan passes on to              at http://www.blueshieldca.com. However, you
   us.                                                     are not required to use a Blue Shield of California
                                                           Plan provider to receive urgent services; you may
Often, this "negotiated price" will consist of a           use any provider. Remember that when you are
simple discount which reflects the actual price            within your Personal Physician service area, ur-
paid by the local Blue Cross and/or Blue Shield            gent services must be provided or authorized by
plan. But sometimes it is an estimated price that          your Personal Physician just like all other non-
factors into the actual price expected settle-             emergency services of the Plan.
ments, withholds, any other contingent payment
arrangements and non-claims transactions with              Follow-up care is also covered through a Blue
your health care provider or with a specified              Shield of California Plan provider and may also
group of providers. The negotiated price may               be received from any provider. However, when
also be billed charges reduced to reflect an aver-         outside your Personal Physician service area au-
age expected savings with your health care pro-            thorization by Blue Shield is required for more
vider or with a specified group of providers.              than two out-of-area follow-up care outpatient
The price that reflects average savings may re-            visits or for care that involves a surgical or other
sult in greater variation (more or less) from the          procedure or inpatient stay. The Blue Shield Ac-


                                                      70
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
cess+ HMO may direct the patient to receive the           information regarding length of stay for mater-
additional follow-up services from the Personal           nity or maternity-related services, see F. Preg-
Physician.                                                nancy and Maternity Care, for information
                                                          relative to the Newborns’ and Mothers’ Health
If services are not received from a Blue Shield           Protection Act.
of California Plan provider, you may be required
to pay the provider for the entire cost of the            Liability of Member for Payment
service and submit a claim to the Blue Shield             It is important to note that all services except
Access+ HMO. Claims for urgent services ob-               for those meeting the emergency and out of ser-
tained outside of your Personal Physician ser-            vice area urgent services requirements, Access+
vice area within California will be reviewed              Specialist visits, hospice program services re-
retrospectively for coverage.                             ceived from a participating hospice agency after
                                                          the Member has been accepted into the hospice
When you receive covered urgent services out-             program, OB/GYN services by an obstetri-
side your Personal Physician service area within          cian/gynecologist or a family practice physician
California, the amount you pay, if not subject to         who is in the same medical group or IPA as the
a flat dollar copayment, is calculated on Blue            Personal Physician, and all mental health and
Shield’s allowed charges.                                 substance abuse services, must have prior au-
                                                          thorization by the Personal Physician, medical
See J. Urgent Services in the Benefit Descrip-            group or IPA. The Member will be responsible
tions section for benefit description, applicable         for payment of services that are not authorized
copayment information, and information on                 or those that are not an emergency or covered
payment responsibility and claims submission.             out of service area urgent service procedures.
                                                          (See the previous Urgent Services paragraphs
Inpatient, Home Health Care                               for information on receiving urgent services out
and Other Services                                        of the service area but within California.) Mem-
The Personal Physician is responsible for ob-             bers must obtain services from the Plan provid-
taining prior authorization before you can be             ers that are authorized by their Personal
admitted to the hospital or a skilled nursing fa-         Physician, medical group or IPA and, for all
cility, including subacute care admissions, except        mental health and substance abuse services,
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 pro-
stays will be determined solely by the Member’s           viders for payment for services if they are a
physician in consultation with the Member. For            benefit of the Plan. When covered services are

                                                     71
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
rendered by a Plan provider, the Member is re-            Member Services Department at 1-800-334-
sponsible only for the applicable copayments,             5847.
except as set forth in the Third Party Recovery
Process and the Member’s Responsibility sec-              For all mental health and substance abuse
tion. Members are responsible for the full                services
charges for any non-covered services they ob-             For all mental health and substance abuse ser-
tain.                                                     vices Blue Shield of California has contracted
                                                          with the Plan’s Mental Health Services Adminis-
Member Identification Card                                trator (MHSA). The MHSA should be contacted
You will receive your Blue Shield Access+                 for questions about mental health and substance
HMO Identification Card after enrollment. If              abuse services, MHSA Participating Providers,
you do not receive your Identification Card or if         or mental health and substance abuse benefits.
you need to obtain medical or prescription ser-           You may contact the MHSA at the telephone
vices before your card arrives, contact the Blue          number or address which appear below:
Shield Member Services Department so that
they can coordinate your care and direct your                             1-877-263-9952
Personal Physician or pharmacy.                               U.S. Behavioral Health Plan, California
                                                              3111 Camino Del Rio North, Suite 600
Member Services Department                                            San Diego, CA 92108
For all services other than mental health and
substance abuse                                           The MHSA can answer many questions over the
If you have a question about services, providers,         telephone.
benefits, how to use this plan, or concerns re-
                                                          The MHSA has established a procedure for our
garding the quality of care or access to care that
                                                          Members to request an expedited decision. A
you have experienced, you should call the Blue
                                                          Member, physician, or representative of a Mem-
Shield Member Services Department at 1-800-
                                                          ber may request an expedited decision when the
334-5847. The hearing impaired may contact
                                                          routine decision making process might seriously
Blue Shield’s Member Services Department
                                                          jeopardize the life or health of a Member, or
through Blue Shield’s toll-free TTY number,
                                                          when the Member is experiencing severe pain.
1-800-241-1823. Member Services can answer
                                                          The MHSA shall make a decision and notify the
many questions over the telephone.
                                                          Member and physician as soon as possible to
Expedited Decision                                        accommodate the Member’s condition not to
                                                          exceed 72 hours following the receipt of the re-
Blue Shield of California has established a pro-
                                                          quest. An expedited decision may involve ad-
cedure for our Members to request an expedited
                                                          missions, continued stay or other health care
decision (including those regarding grievances).
                                                          services. If you would like additional informa-
A Member, physician, or representative of a
                                                          tion regarding the expedited decision process, or
Member may request an expedited decision
                                                          if you believe your particular situation qualifies
when the routine decision making process might
                                                          for an expedited decision, please contact the
seriously jeopardize the life or health of a Mem-
                                                          MHSA at the number listed above.
ber, or when the Member is experiencing severe
pain. Blue Shield shall make a decision and no-
                                                          For information on additional rights, see the
tify the Member and physician as soon as possi-
                                                          Grievance Process section.
ble to accommodate the Member’s condition
not to exceed 72 hours following the receipt of
the request. An expedited decision may involve
admissions, 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 our

                                                     72
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Rates for Supplement to Original                                             Contracting Agency Employees and
Medicare Plan                                                                Annuitants
Cost of the Program                                                          The rates shown above are effective January 1,
Type of Enrollment                                Monthly Rate               2008, and will be reduced by the amount your
                                                                             contracting agency contributes toward the cost
Employee only ................................................$341.44        of your health benefit plan. This amount varies
Employee and one dependent......................$682.88                      among public agencies. For assistance on calcu-
Employee and two or more dependents ..$1024.32                               lating your net contribution, contact your agency
                                                                             or retirement system health benefits officer.
State Employees and Annuitants
The rates shown above are effective January 1,                               Rate Change
2008, and will be reduced by the amount the                                  The plan rates may be changed as of January 1,
State of California contributes toward the cost                              2009, following at least 60 days’ written notice
of your health benefit plan. These contribution                              to the Board prior to such change.
amounts are subject to change as a result of col-
lective bargaining agreements or legislative ac-
tion. Any such change will be accomplished by
the State Controller or affected retirement sys-
tem without any action on your part. For cur-
rent contribution information, contact your
retirement system health benefits officer.




                                                                        73
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
Benefit Descriptions                                       e. Operating room, special treatment
For additional information concerning covered                 rooms, delivery room, newborn nursery
benefits, contact the Health Insurance Counsel-               and related facilities;
ing and Advocacy Program (HICAP) or
CalPERS. HICAP provides health insurance                   f. Hospital ancillary services including di-
counseling for California senior citizens. Call the           agnostic laboratory, x-ray services and
HICAP toll-free telephone number, 1-800-434-                  therapy services;
0222, for a referral to your local HICAP office.           g. Drugs, medications, biologicals, and
HICAP is a service provided free of charge by                 oxygen administered in the hospital, and
the State of California.                                      up to 3 days’ supply of drugs supplied
                                                              upon discharge by the Plan physician for
The Plan benefits available to you are listed in
                                                              the purpose of transition from the hospi-
this section. The copayments for these services,
                                                              tal to home;
if applicable, follow each benefit description.
                                                           h. Surgical and anesthetic supplies, dress-
The following are the basic health care services              ings and cast materials, surgically im-
covered by the Blue Shield Access+ HMO                        planted devices and prostheses, other
without charge to the Member, except for co-                  medical supplies and medical appliances
payments where noted, and as set forth in the                 and equipment administered in hospital;
Third Party Recovery Process and the Member’s
Responsibility section. These services are cov-            i. Processing, storage and administration of
ered when medically necessary, and when pro-                  blood, and blood products (plasma), in
vided by the Member’s Personal Physician or                   inpatient and outpatient settings. In-
other Plan provider or authorized as described                cludes the storage and collection of
herein, or received according to the provisions               autologous blood;
described under Obstetrical/Gynecological
(OB/GYN) Physician Services, Access+ Spe-                  j. Radiation therapy, chemotherapy and re-
cialist, and Mental Health and Substance Abuse                nal dialysis;
Services. Coverage for these services is subject
to all terms, conditions, limitations and exclu-           k. Respiratory therapy and other diagnostic,
sions of the Agreement, to any conditions or                  therapeutic and rehabilitation services as
limitations set forth in the benefit descriptions             appropriate;
below, and to the Exclusions and Limitations               l. Coordinated discharge planning, includ-
set forth in this booklet.                                    ing the planning of such continuing care
                                                              as may be necessary;
A. Hospital Services
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
                                                              disabled who meet these criteria. Ex-
    b. General nursing care, and special duty                 cludes services of dentist or oral surgeon;
       nursing when medically necessary;
                                                           n. Subacute care;
    c. Meals and special diets when medically
       necessary;                                          o. Medically necessary inpatient substance
                                                              abuse detoxification services required to
    d. Intensive care services and units;

                                                      74
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
       treat potentially life-threatening symp-                able a Member to properly use asthma-
       toms of acute toxicity or acute with-                   related medication and equipment such as
       drawal are covered when a covered                       inhalers, spacers, nebulizers and peak flow
       Member is admitted through the emer-                    monitors.
       gency room or when medically necessary
       inpatient substance abuse detoxification                    Copayment: $10 per visit.
       is prior authorized;
                                                            2. Allergy Testing and Treatment
    p. Rehabilitation when furnished by the
       hospital and authorized.                                Office visits for the purpose of allergy test-
                                                               ing and treatment, including injectables and
See Section O. for inpatient hospital services                 serum.
provided under the “Hospice Program Services”
benefit.                                                           Copayment: $10 per visit or treatment.

        Copayment: No charge.                               3. Inpatient Medical and Surgical Services

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
       age of 7 and the developmentally dis-                       Copayment: $10 per visit.
       abled who meet these criteria. Excludes
       services of dentist or oral surgeon.                 5. Treatment of physical complications of a
                                                               mastectomy, including lymphedemas
        Copayment: No charge.
                                                                   Copayment: $10 per visit.
B. Physician Services (Other Than for
   Mental Health and Substance Abuse                        6. Internet-Based Consultations. Medically
   Services)                                                   necessary consultations with Internet Ready
1. Physician Office Visits                                     Physicians via Blue Shield approved Internet
                                                               portal. Internet-based consultations are
    Office visits for examination, diagnosis and               available only to Members whose Personal
    treatment of a medical condition, disease or               Physicians (or other physicians to whom
    injury, including specialist office visits, sec-           you have been referred for care within your
    ond opinion or other consultations, diabetic               Personal Physician’s medical group or IPA)
    counseling, and OB/GYN services from an                    have agreed to provide Internet-based con-
    obstetrician/gynecologist or a family prac-                sultations via the Blue Shield approved
    tice physician who is within the same medi-                Internet portal (“Internet Ready”). Internet-
    cal group or IPA as the Personal Physician.                based consultations for mental health and
    Benefits are also provided for asthma self-                substance abuse care are not covered. Refer
    management training and education to en-                   to the On-Line Physician Directory to de-

                                                       75
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    termine whether your physician is Internet           2. Vision screening by the Personal Physician
    Ready and how to initiate an Internet-based             for Members to determine the need for a re-
    consultation. This information can be ac-               fraction for vision correction.
    cessed at http://www.blueshieldca.com.
                                                         3. Hearing screening by the Personal Physician
        Copayment: $10 per consultation.                    for Members to determine the need for an
                                                            audiogram for hearing correction, as well as
C. Preventive Health Services                               newborn hearing screening services.
Preventive care services are those primary pre-
ventive medical services provided by a physician                 Copayment: $10 per visit. (Applicable
for the early detection of disease when no symp-                 to 1-3, above.)
toms are present and for those items specifically
listed below.                                            4. Influenza virus vaccine once a year. Pneu-
                                                            monia vaccine as prescribed by doctor.
1. Scheduled routine physical examinations as               Hepatitis B vaccine if at medium or high
   follows:                                                 risk.

    • Exams every year, age 3-19 years;                          Copayment: No charge. All other im-
    • Exams every 5 years, age 20-40 years;                      munizations $10 per immunization.
    • Exams every 2 years, age 41-50 years;
                                                         5. Eye refraction to determine the need for
    • Exams every year over age 50 years;                   corrective lenses for all Members upon re-
    • Routine breast and pelvic exams and                   ferral by the Personal Physician.
      Pap tests or other Food and Drug
      Administration (FDA) approved cer-                         Copayment: $10 per visit. (Limited to
      vical and vaginal cancer and human                         one visit per calendar year, for Mem-
      papillomavirus virus (HPV) screening                       bers aged 18 and over. No limit on
      tests every year. A woman may self-                        number of visits for Members under
      refer to an obstetrician/gynecologist                      age 18.)
      or a family practice physician who is in
      the same medical group or IPA as her               6. Nurse support: As part of Lifepath Advis-
      Personal Physician for a routine an-                  ers, Members may call a registered nurse via
      nual gynecological exam;                              1-866-543-3728, a 24-hour, toll-free number
    • Mammography for screening purposes                    to receive confidential advice and informa-
      as recommended by Member’s Per-                       tion about minor illnesses and injuries,
      sonal Physician;                                      chronic conditions, fitness, nutrition and
    • Annual gynecological exam - annual                    other health-related topics.
      routine examination by an obstetri-
      cian/gynecologist without a referral                       Copayment: No charge.
      from the Member’s Personal Physi-
      cian, as long as the obstetri-                     See Section D. for information on coverage of
      cian/gynecologist is in the same                   genetic testing and diagnostic procedures.
      medical group or IPA as her Personal
      Physician;                                         D. Diagnostic X-ray/Lab Services
    • Includes coverage for the screening                1. X-ray, Laboratory, Major Diagnostic Ser-
      and diagnosis of prostate cancer, in-                 vices. All outpatient diagnostic x-ray and
      cluding, but not limited to, prostate-                clinical laboratory tests and services, includ-
      specific antigen testing and digital rec-             ing diagnostic imaging, electrocardiograms,
      tal examinations, when medically nec-                 and diagnostic clinical isotope services.
      essary and consistent with good
                                                         2. Genetic Testing and Diagnostic Procedures.
      medical practice.
                                                            Genetic testing for certain conditions when

                                                    76
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    the Member has risk factors such as family                 b. Medically necessary repairs and mainte-
    history or specific symptoms. The testing                     nance of durable medical equipment, as
    must be expected to lead to increased or al-                  authorized by Plan provider. Repair is
    tered monitoring for early detection of dis-                  covered unless necessitated by misuse or
    ease, a treatment plan or other therapeutic                   loss.
    intervention and determined to be medically
    necessary and appropriate in accordance                    c. Rental charges for durable medical
    with Blue Shield of California medical pol-                   equipment in excess of the purchase
    icy.                                                          price are not covered.

See Section F. for genetic testing for prenatal di-            d. Benefits do not include environmental
agnosis of genetic disorders of the fetus.                        control equipment or generators. No
                                                                  benefits are provided for backup or al-
        Copayment: No charge.                                     ternate items.
                                                            See Section V. for devices, equipment and sup-
E. Durable Medical Equipment,
                                                            plies for the management and treatment of dia-
   Prostheses and Orthoses and                              betes.
   Other Services
Medically necessary durable medical equipment,              If you are enrolled in a hospice program
prostheses and orthoses for activities of daily             through a participating hospice agency, medical
living, and supplies needed to operate durable              equipment and supplies that are reasonable and
medical equipment; oxygen and oxygen equip-                 necessary for the palliation and management of
ment and its administration; blood glucose                  terminal illness and related conditions are pro-
monitors as medically appropriate for insulin               vided by the hospice agency. For information
dependent, non-insulin dependent and gesta-                 see Section O.
tional diabetes; apnea monitors; and ostomy and
medical supplies to support and maintain gastro-            2. Prostheses
intestinal, bladder or respiratory function are
covered. Benefits are provided at the most cost-               a. Medically necessary prostheses for activi-
effective level of care that is consistent with pro-              ties of daily living, including the follow-
fessionally recognized standard of practice. If                   ing:
there are two or more professionally recognized
items equally appropriate for a condition, bene-                   1) Supplies necessary for the operation
fits will be based on the most cost-effective                         of prostheses;
item.
                                                                   2) Initial fitting and replacement after
1. Durable Medical Equipment                                          the expected life of the item;
                                                                   3) Repairs, even if due to damage;
    a. Replacement of durable medical equip-
       ment is covered only when it no longer                      4) Blom-Singer and artificial larynx pros-
       meets the clinical needs of the patient or                     theses for speech following a laryn-
       has exceeded the expected lifetime of the                      gectomy;
       item.*
                                                                   5) Prosthetic devices used to restore a
       *This does not apply to the medically                          method of speaking following laryn-
       necessary replacement of nebulizers, face                      gectomy, including initial and subse-
       masks and tubing, and peak flow moni-                          quent prosthetic devices and
       tors for the management and treatment                          installation accessories. This does not
       of asthma. (See Section P. for benefits                        include electronic voice producing
       for asthma inhalers and inhaler spacers.)                      machines;


                                                       77
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
      6) Cochlear implants;                                        motion and positioning when im-
                                                                   provement has not occurred with a
      7) Contact lenses if medically necessary                     trial of strapping or an over-the-
         to treat eye conditions such as kerato-                   counter stabilizing device;
         conus, keratitis sicca or aphakia. Cata-
         ract spectacles or intraocular lenses                  3) Medically necessary knee braces for
         that replace the natural lens of the eye                  post-operative rehabilitation follow-
         after cataract surgery. If medically                      ing ligament surgery, instability due to
         necessary with the insertion of the in-                   injury, and to reduce pain and insta-
         traocular lens, one pair of conven-                       bility for patients with osteoarthritis.
         tional eyeglasses or contact lenses;
                                                            b. Benefits for medically necessary orthoses
      8) Artificial limbs and eyes.                            are provided at the most cost-effective
                                                               level of care that is consistent with pro-
   b. Routine maintenance is not covered.                      fessionally recognized standards of prac-
                                                               tice. If there are two or more
   c. Benefits do not include wigs for any rea-
                                                               professionally recognized appliances
      son, self-help/educational devices or any
                                                               equally appropriate for a condition, the
      type of speech or language assistance de-
                                                               Plan will provide benefits based on the
      vices, except as specifically provided
                                                               most cost-effective appliance. Routine
      above. See the Exclusions and Limita-
                                                               maintenance is not covered. No benefits
      tions section for a listing of excluded
                                                               are provided for backup or alternate
      speech and language assistance devices.
                                                               items.
      No benefits are provided for backup or
      alternate items.                                      c. Benefits are provided for orthotic de-
                                                               vices for maintaining normal activities of
   For surgically implanted and other pros-
                                                               daily living only. No benefits are pro-
   thetic devices (including prosthetic bras)
                                                               vided for orthotic devices such as knee
   provided to restore and achieve symmetry
                                                               braces intended to provide additional
   incident to a mastectomy, see Section W.
                                                               support for recreational or sports activi-
   Blom-Singer and artificial larynx prostheses
                                                               ties or for orthopedic shoes and other
   for speech following a laryngectomy are
                                                               supportive devices for the feet.
   covered as a surgical professional benefit.
                                                                Copayment: No charge.
3. Orthoses
                                                         See Section V. for devices, equipment and sup-
   a. Medically necessary orthoses for activi-           plies for the management and treatment of dia-
      ties of daily living, including the follow-        betes.
      ing:
                                                         F. Pregnancy and Maternity Care
      1) Special footwear required for foot
         disfigurement which includes but is             The following pregnancy and maternity care is
         not limited to foot disfigurement               covered subject to the General Exclusions and
         from cerebral palsy, arthritis, polio,          Limitations.
         spina bifida, diabetes or by accident
                                                         1. Prenatal and Postnatal Physician Office Vis-
         or developmental disability;
                                                            its
      2) Medically necessary functional foot
         orthoses that are custom made rigid                See Section D. for information on coverage
         inserts for shoes, ordered by a physi-             of other genetic testing and diagnostic pro-
         cian or podiatrist, and used to treat              cedures.
         mechanical problems of the foot, an-
         kle or leg by preventing abnormal

                                                    78
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
2. Inpatient Hospital and Professional Ser-                  scribed by the provider to diagnose and
   vices. Hospital and Professional services for             treat the cause of infertility.
   the purposes of a normal delivery, C-
   section, complications or medical conditions                  Copayment: 50% of allowed charges
   arising from pregnancy or resulting child-                    for all services.
   birth.
                                                          3. Sterilization Procedures, including Tubal
3. Includes providing coverage for all testing               Ligation and Vasectomy
   recommended by the California Newborn
   Screening Program and for participating in                    Copayment: See applicable copay-
   the statewide prenatal testing program, ad-                   ments for Physician Services and Hos-
   ministered by the State Department of                         pital Services.
   Health Services, known as the Expanded
                                                          4. Elective Abortion
   Alpha Feto Protein Program.
                                                                 Copayment: See applicable copay-
        Copayment: No charge.
                                                                 ments for Physician Services and Hos-
                                                                 pital Services.
The Newborns' and Mothers' Health Protection
Act requires group health plans to provide a
                                                          5. Contraceptive Devices and Fitting
minimum hospital stay for the mother and new-
born child of 48 hours after a normal, vaginal                   Copayment: $10 per visit; $5 per device
delivery and 96 hours after a C-section unless                   in conjunction with office visit. Dia-
the attending physician, in consultation with the                phragms also covered under Section
mother, determines a shorter hospital length of                  P.; see applicable copayments for Pre-
stay is adequate.                                                scription Drugs.

If the hospital stay is less than 48 hours after a        6. Oral Contraceptives
normal, vaginal delivery or less than 96 hours af-
ter a C-section, a follow-up visit for the mother                Copayment: See applicable copay-
and newborn within 48 hours of discharge is                      ments for Prescription Drugs.
covered when prescribed by the treating physi-
cian. This visit shall be provided by a licensed          7. Injectable Contraceptives, excluding inter-
health care provider whose scope of practice in-             nally implanted time release contraceptives
cludes postpartum and newborn care. The treat-
ing physician, in consultation with the mother,                  Copayment: $10 per visit; $15 for each
shall determine whether this visit shall occur at                injection.
home, the contracted facility, or the physician’s
office.                                                   H. Ambulance Services
                                                          The Plan will pay for ambulance services as fol-
G. Family Planning and Infertility Services               lows:
1. Family Planning Counseling
                                                          1. Emergency Ambulance Services
        Copayment: No charge.
                                                             For transportation to the nearest hospital
2. Infertility Services. Infertility services (in-           which can provide such emergency care
   cluding artificial insemination), except as ex-           only if a reasonable person would have be-
   cluded in the General Exclusions and                      lieved that the medical condition was an
   Limitations, including professional, hospital,            emergency medical condition which re-
   ambulatory surgery center, ancillary services             quired ambulance services, as described in
   and injectable drugs administered or pre-                 Section I.



                                                     79
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
2. Non-Emergency Ambulance Services                      3. The services will be reviewed retrospectively
                                                            by the Plan to determine whether the ser-
   Medically necessary ambulance services to                vices were for a medical condition for which
   transfer the Member from a non-Plan hos-                 a reasonable person would have believed
   pital to a Plan hospital, between Plan facili-           that they had an emergency medical condi-
   ties, or from facility to home when in                   tion.
   connection with authorized confinement/
   admission and the use of the ambulance is                    Copayment: $50 per visit in the hospi-
   authorized.                                                  tal emergency room. (Emergency ser-
                                                                vices copayment is waived if Member
       Copayment: No charge.                                    is admitted directly to hospital as an
                                                                inpatient from emergency room or
I. Emergency Services                                           kept for observation and hospital bills
An emergency means an unexpected medical                        for an emergency room observation
condition manifesting itself by acute symptoms                  visit.)
of sufficient severity (including severe pain)
such that a layperson who possesses an average           4. Continuing or Follow-up Treatment. The
knowledge of health and medicine could rea-                 Plan will provide benefits for care in a non-
sonably assume that the absence of immediate                Plan hospital only for as long as the Mem-
medical attention could be expected to result in            ber’s medical condition prevents transfer to
any of the following: (1) placing the Member’s              a Plan hospital in the Member’s service area,
health in serious jeopardy, (2) serious impair-             as approved by the medical group or IPA or
ment to bodily functions, (3) serious dysfunc-              by Blue Shield. Unauthorized continuing or
tion of any bodily organ or part. If you receive            follow-up care after the initial emergency
services in a situation that the Blue Shield Ac-            has been treated in a non-Plan hospital, or
cess+ HMO determines was not a situation in                 by a non-Plan provider is not a covered ser-
which a reasonable person would believe that an             vice.
emergency condition existed, you will be re-
                                                         5. Claims for Emergency and Out-of-Area Ur-
sponsible for the costs of those services.
                                                            gent Services. Contact Member Services to
1. Members who reasonably believe that they                 obtain a claim form.
   have an emergency medical or mental health
                                                            a. Emergency. If emergency services were
   condition which requires an emergency re-
                                                               received and expenses were incurred by
   sponse are encouraged to appropriately use
                                                               the Member, for services other than
   the “911” emergency response system
                                                               medical transportation, the Member
   where available. The Member should notify
                                                               must submit a complete claim with the
   the Personal Physician or the MHSA by
                                                               emergency service record for payment to
   phone within 24 hours of the commence-
                                                               the Plan, within 1 year after the first pro-
   ment of the emergency services, or as soon
                                                               vision of emergency services for which
   as it is medically possible for the Member to
                                                               payment is requested. If the claim is not
   provide notice. Failure to provide notice as
                                                               submitted within this period, the Plan
   stated will result in the services not being
                                                               will not pay for those emergency ser-
   covered.
                                                               vices, unless the claim was submitted as
2. Whenever possible, go to the emergency                      soon as reasonably possible as deter-
   room of your nearest Blue Shield Access+                    mined by the Plan. If the services are not
   HMO hospital for medical emergencies. A                     pre-authorized, the Plan will review the
   listing of Blue Shield Access+ HMO hospi-                   claim retrospectively for coverage. If the
   tals is available in your HMO Physician and                 Plan determines that these services re-
   Hospital Directory.                                         ceived were for a medical condition for
                                                               which a reasonable person would not
                                                               reasonably believe that an emergency

                                                    80
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
       condition existed and would not other-              1. When within California, but outside of your
       wise have been authorized, and, there-                 Personal Physician service area, if possible
       fore, are not covered, it will notify the              contact Blue Shield Member Services at
       Member of that determination. The Plan                 1-800-334-5847 for assistance in receiving
       will notify the Member of its determina-               urgent services. Member Services will assist
       tion within 30 days from receipt of the                Members in receiving urgent services
       claim. In the event covered medical                    through a Blue Shield of California Plan
       transportation services are obtained in                provider. Members may also locate a Plan
       such an emergency situation, the Blue                  provider by visiting Blue Shield’s internet site
       Shield Access+ HMO shall pay the                       at http://www.blueshieldca.com. You are
       medical transportation provider directly.              not required to use a Blue Shield of Califor-
                                                              nia Plan provider to receive urgent services;
    b. Out-of-Area Urgent Services. If out-of-                you may use any provider. However, the
       area urgent services were received from a              services will be reviewed retrospectively by
       non-participating BlueCard Program                     the Plan to determine whether the services
       provider, you must submit a complete                   were urgent services.
       claim with the urgent service record for
       payment to the Plan, within 1 year after            2. When temporarily traveling within the
       the first provision of urgent services for             United States, call the 24-hour toll-free
       which payment is requested. If the claim               number 1-800-810-BLUE (2583) to obtain
       is not submitted within this period, the               information about the nearest BlueCard
       Plan will not pay for those urgent ser-                Program participating provider. When a
       vices, unless the claim was submitted as               BlueCard Program participating provider is
       soon as reasonably possible as deter-                  available, you should obtain out-of-area ur-
       mined by the Plan. The services will be                gent or follow-up care from a participating
       reviewed retrospectively by the Plan to                provider whenever possible, but you may
       determine whether the services were ur-                also receive care from a non-participating
       gent services. If the Plan determines that             BlueCard Program provider. If you received
       the services would not have been author-               services from a non-Blue Shield provider,
       ized, and therefore, are not covered, it               you must submit a claim to Blue Shield for
       will notify the Member of that determi-                payment. The services will be reviewed ret-
       nation. The Plan will notify the Member                rospectively by the Plan to determine
       of its determination within 30 days from               whether the services were urgent services.
       receipt of the claim.                                  See Section I.5. Claims for Emergency and
                                                              Out-of-Area Urgent Services for additional
J. Urgent Services                                            information.
Urgent services are provided in response to the
patient’s need for a prompt diagnostic workup                  Up to two medically necessary out-of-area
and/or treatment.                                              follow-up care outpatient visits are covered.
                                                               Authorization by Blue Shield is required for
These services are applicable for a medical or                 more than two follow-up outpatient visits or
mental disorder that: (1) could become an                      for care that involves a surgical or other
emergency if not diagnosed and/or treated in a                 procedure or inpatient stay. Blue Shield may
timely manner, (2) is likely to result in prolonged            direct the Member to receive the additional
temporary impairment, (3) could increase the                   follow-up care from the Personal Physician.
risk of necessitating more complex or hazardous
treatment, and (4) could develop in a chronic              3. When outside the United States, Members
illness or inordinate physical or psychological               may call the BlueCard Worldwide Network
suffering of the patient.                                     at 1-804-673-1177. Urgent services are avail-
                                                              able through the BlueCard Worldwide Net-



                                                      81
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
   work, but may be received from any pro-                      3) Certified home health aide in con-
   vider.                                                          junction with the services of 1) or 2),
                                                                   above;
   Before traveling abroad, Members should
   call their local Member Services office for                   Copayment: No charge.
   the most current listing of participating pro-
   viders worldwide or they can go on-line at                   4) Physical     therapist,   occupational
   www.bcbs.com and select the “Find a Doc-                        therapist, or speech therapist.
   tor or Hospital” tab. However, a Member is
                                                                 Copayment: $10 per visit.
   not required to receive urgent services out-
   side of the United States from the BlueCard               b. Medical Social Worker. Medical social
   Worldwide Network. If the Member does                        services provided by a licensed medical
   not use the BlueCard Worldwide Network, a                    social worker for consultation and
   claim must be submitted as described in                      evaluation.
   Section I.5. Claims for Emergency and Out-
   of-Area Urgent Services.                                      Copayment: No charge.

4. Remember that when you are within your                    c. In conjunction with the professional ser-
   service area, urgent services must be pro-                   vices rendered by a home health agency,
   vided or authorized by your Personal Physi-                  medications, drugs and medical supplies
   cian just like all other non-emergency                       used during a covered visit by the home
   services of the Plan. Whenever possible, you                 health agency necessary for the home
   should contact your Personal Physician. Ur-                  health care treatment plan, and related
   gent services required when the Member is                    pharmaceutical and laboratory services to
   within the Plan service area, but not within                 the extent the benefit would have been
   your own service area, must be obtained in                   provided had the Member remained in
   accordance with all the conditions of the                    the hospital, except as excluded in the
   Agreement.                                                   General Exclusions and Limitations. This
                                                                benefit includes: parenteral and enteral nutri-
       Copayment: $25 per visit.                                tional services and associated supplies and sup-
                                                                plements.
K. Home Health Care Services,
   PKU-Related Formulas and                                      Copayment: No charge.
   Special Food Products, and
   Home Infusion Therapy                                 Skilled Nursing Services. A level of care that in-
                                                         cludes services that can only be performed
1. Home Health Care Services
                                                         safely and correctly by a licensed nurse (either a
   The following Home Health Care services               registered nurse or a licensed practical nurse).
   will be covered when the patient is required
                                                         See Section O. for a specialized description of
   to be at home for medically necessary pur-
                                                         skilled nursing services for hospice care.
   poses at the direction of the Personal Physi-
   cian and authorized.
                                                         For information concerning “Hospice Program
                                                         Services” see Section O.
   a. Home visits to provide skilled nursing
      services and other skilled services by any
                                                         2. PKU-Related Formulas and Special Food
      of the following professional providers
                                                            Products
      are covered:
       1) Registered nurse;                                  Benefits are provided for enteral formulas
                                                             and special food products that are medically
       2) Licensed vocational nurse;                         necessary to avert the development of seri-
                                                             ous physical or mental disabilities or to

                                                    82
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    promote normal development or function                 nosed and identifiable medical condition, illness,
    as a consequence of phenylketonuria (PKU).             or injury to the nervous system or to the vocal,
    These benefits must be prior authorized by             swallowing, or auditory organs.
    Blue Shield and must be prescribed or or-
    dered by the appropriate health care profes-           Continued outpatient benefits will be provided
    sional.                                                for medically necessary services as long as con-
                                                           tinued treatment is medically necessary, pursu-
        Copayment: No charge.                              ant to the treatment plan, and likely to result in
                                                           clinically significant progress as measured by ob-
3. Home Infusion/IV Injectable Therapy Pro-                jective and standardized tests. The provider’s
   vided by a Home Infusion Agency                         treatment plan and records will be reviewed pe-
                                                           riodically. When continued treatment is not
    Benefits are provided for home infusion                medically necessary pursuant to the treatment
    therapy and medical supplies, including the            plan, not likely to result in additional clinically
    cost of pharmaceuticals administered intra-            significant improvement, or no longer requires
    venously; and for medically necessary, FDA             skilled services of a licensed speech therapist,
    approved injectable medications, when pre-             the Member will be notified of this determina-
    scribed by the Personal Physician and prior            tion and benefits will not be provided for ser-
    authorized.                                            vices rendered after the date of written
                                                           notification.
    This benefit does not include insulin or
    home self-administered injectables, which              Except as specified above and as stated under
    are covered under Section P.                           Section K., no outpatient benefits are provided
                                                           for speech therapy, speech correction, or speech
        Copayment: No charge.                              pathology services.
For information concerning diabetes self-                          Copayment: $10 per visit for inpatient
management training, see Section V.                                or outpatient therapy.

L. Physical and Occupational Therapy                       See Section K. for information on coverage for
Rehabilitation services include physical therapy,          speech therapy services rendered in the home.
occupational therapy, and/or respiratory ther-             See Section A. for information on inpatient
apy. Benefits for speech therapy are described in          benefits and Section O. for hospice program
Section M.                                                 services.

        Copayment: $10 per visit for inpatient             N. Skilled Nursing Facility Services
        or outpatient therapy.                             Subject to all of the inpatient hospital services
                                                           provisions under Section A., medically necessary
M. Speech Therapy                                          skilled nursing services, including subacute care,
Initial outpatient benefits for speech therapy             will be covered when provided in a skilled nurs-
services when diagnosed and ordered by a phy-              ing facility and authorized. This benefit is lim-
sician and provided by an appropriately licensed           ited to 100 days during any calendar year except
speech therapist, pursuant to a written treatment          when received through a hospice program pro-
plan for an appropriate time to: (1) correct or            vided by a participating hospice agency. Custo-
improve the speech abnormality, or (2) evaluate            dial care is not covered.
the effectiveness of treatment, and when ren-
dered in the provider’s office or outpatient de-           For information concerning “Hospice Program
partment of a hospital.                                    Services” see Section O.
Services are provided for the correction of, or                    Copayment: No charge.
clinically significant improvement of, speech
abnormalities that are the likely result of a diag-

                                                      83
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
O. Hospice Program Services                               3. Skilled nursing services, certified health aide
Benefits are provided for the following services             services and homemaker services under the
through a participating hospice agency when an               supervision of a qualified registered nurse.
eligible Member requests admission to and is
formally admitted to an approved hospice pro-             4. Bereavement services.
gram. The Member must have a terminal illness
as determined by his Plan provider’s certifica-           5. Social services/counseling services with
tion and the admission must receive prior ap-                medical social services provided by a quali-
proval from Blue Shield. (Note: Members with                 fied social worker. Dietary counseling, by a
a terminal illness who have not elected to enroll            qualified provider, shall also be provided
in a hospice program can receive a pre-hospice               when needed.
consultative visit from a participating hospice
agency.) Covered services are available on a 24-          6. Medical direction with the medical director
hour basis to the extent necessary to meet the               being also responsible for meeting the gen-
needs of individuals for care that is reasonable             eral medical needs for the terminal illness of
and necessary for the palliation and manage-                 the Members to the extent that these needs
ment of terminal illness and related conditions.             are not met by the Personal Physician.
Members can continue to receive covered ser-
                                                          7. Volunteer services.
vices that are not related to the palliation and
management of the terminal illness from the
                                                          8. Short-term inpatient care arrangements.
appropriate Plan provider. Member copayments
when applicable are paid to the participating             9. Pharmaceuticals, medical equipment and
hospice agency.                                              supplies that are reasonable and necessary
                                                             for the palliation and management of termi-
Note: Hospice services provided by a non-
                                                             nal illness and related conditions.
participating hospice agency are not covered ex-
cept in certain circumstances in counties in Cali-        10. Physical therapy, occupational therapy, and
fornia in which there are no participating                    speech-language pathology services for pur-
hospice agencies. If Blue Shield prior authorizes             poses of symptom control, or to enable the
hospice program services from a non-contracted                enrollee to maintain activities of daily living
hospice, the Member’s copayment for these ser-                and basic functional skills.
vices will be the same as the copayments for
hospice program services when received and au-            11. Nursing care services are covered on a con-
thorized by a participating hospice agency.                   tinuous basis for as much as 24 hours a day
                                                              during periods of crisis as necessary to
All of the services listed below must be received             maintain a Member at home. Hospitaliza-
through the participating hospice agency.                     tion is covered when the Interdisciplinary
                                                              Team makes the determination that skilled
1. Pre-hospice consultative visit regarding pain
                                                              nursing care is required at a level that cannot
   and symptom management, hospice and
                                                              be provided in the home. Either home-
   other care options including care planning
                                                              maker services or home health aide services
   (Members do not have to be enrolled in the
                                                              or both may be covered on a 24-hour con-
   hospice program to receive this benefit).
                                                              tinuous basis during periods of crisis but the
                                                              care provided during these periods must be
2. Interdisciplinary Team care with develop-
                                                              predominantly nursing care.
   ment and maintenance of an appropriate
   plan of care and management of terminal
                                                          12. Respite care services are limited to an occa-
   illness and related conditions.
                                                              sional basis and to no more than 5 consecu-
                                                              tive days at a time.



                                                     84
SUPPLEMENT TO ORIGINAL MEDICARE 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
services or home health aide services may be                 of care and appropriateness of services for
provided to supplement the nursing care. When                those Members who cannot be managed at
fewer than 8 hours of nursing care are required,             home because of acute complications or the
the services are covered as routine home care                temporary absence of a capable primary
rather than continuous home care.                            caregiver.

Home Health Aide Services - services provid-              4. Provides for the palliative medical treatment
ing for the personal care of the terminally ill              of pain and other symptoms associated with
Member and the performance of related tasks in               a terminal disease, but does not provide for
the Member’s home in accordance with the plan                efforts to cure the disease.
of care in order to increase the level of comfort
and to maintain personal hygiene and a safe,              5. Provides for bereavement services following
healthy environment for the patient. Home                    the Member’s death to assist the family to
health aide services shall be provided by a per-             cope with social and emotional needs asso-
son who is certified by the California Depart-               ciated with the death of the Member.
ment of Health Services as a home health aide
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.



                                                     85
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
8. Is provided through a participating hospice           the Interdisciplinary Team and the Member’s
   agency.                                               Plan provider to a Member and his family that
                                                         pertain to the palliative, supportive services re-
Interdisciplinary Team - the hospice care                quired by a Member with a terminal illness.
team that includes, but is not limited to, the           Skilled nursing services include, but are not lim-
Member and the Member’s family, a physician              ited to, Member assessment, evaluation and case
and surgeon, a registered nurse, a social worker,        management of the medical nursing needs of
a volunteer, and a spiritual caregiver.                  the Member, the performance of prescribed
                                                         medical treatment for pain and symptom con-
Medical Direction - services provided by a li-           trol, the provision of emotional support to both
censed physician and surgeon who is charged              the Member and his family, and the instruction
with the responsibility of acting as a consultant        of caregivers in providing personal care to the
to the Interdisciplinary Team, a consultant to           enrollee. Skilled nursing services provide for the
the Member’s Personal Physician, as requested,           continuity of services for the Member and his
with regard to pain and symptom management,              family and are available on a 24-hour on-call ba-
and liaison with physicians and surgeons in the          sis.
community. For purposes of this section, the
person providing these services shall be referred        Social Service/Counseling Services - those
to as the “medical director”.                            counseling and spiritual services that assist the
                                                         Member and his family to minimize stresses and
Period of Care - the time when the Personal              problems that arise from social, economic, psy-
Physician recertifies that the Member still needs        chological, or spiritual needs by utilizing appro-
and remains eligible for hospice care even if the        priate community resources, and maximize
Member lives longer than 1 year. A period of             positive aspects and opportunities for growth.
care starts the day the Member begins to receive
hospice care and ends when the 90 or 60-day              Terminal Disease or Terminal Illness - a
period has ended.                                        medical condition resulting in a prognosis of life
                                                         of 1 year or less, if the disease follows its natural
Period of Crisis - a period in which the Mem-            course.
ber requires continuous care to achieve pallia-
tion or management of acute medical                      Volunteer Services - services provided by
symptoms.                                                trained hospice volunteers who have agreed to
                                                         provide service under the direction of a hospice
Plan of Care - a written plan developed by the           staff member who has been designated by the
attending physician and surgeon, the “medical            hospice to provide direction to hospice volun-
director” (as defined under “Medical Direc-              teers. Hospice volunteers may provide support
tion”) or physician and surgeon designee, and            and companionship to the Member and his fam-
the Interdisciplinary Team that addresses the            ily during the remaining days of the Member’s
needs of a Member and family admitted to the             life and to the surviving family following the
hospice program. The hospice shall retain over-          Member’s death.
all responsibility for the development and main-
tenance of the plan of care and quality of                        Copayment: No charge.
services delivered.
                                                         P. Prescription Drugs
Respite Care Services - short-term inpatient             Except for the calendar year maximum copayments and
care provided to the Member only when neces-             the Coordination of Benefits provision, the general provi-
sary to relieve the family members or other per-         sions and exclusions of the HMO Health Plan Agree-
sons caring for the Member.                              ment shall apply.
Skilled Nursing Services - nursing services              This plan's prescription drug coverage is on average
provided by or under the supervision of a regis-         equivalent to or better than the standard benefit set by
tered nurse under a plan of care developed by

                                                    86
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
the federal government for Medicare Part D (also called            considered for inclusion or exclusion from the
creditable coverage). Because this Plan’s prescription drug        Formulary are reviewed by Blue Shield’s Phar-
coverage is creditable, you do not have to enroll in Medi-         macy and Therapeutics Committee during
care Part D while you maintain this coverage; however,             scheduled meetings four times a year.
you should be aware that if you have a subsequent break
in this coverage of 63 days or more before enrolling in            Members may call Blue Shield Member Services
Medicare Part D you could be subject to payment of                 at the number listed on their Blue Shield Identi-
higher Part D premiums.                                            fication Card to inquire if a specific drug is in-
                                                                   cluded in the Formulary. Member Services can
Benefits are provided for outpatient prescription                  also provide Members with a printed copy of
drugs which meet all of the requirements speci-                    the Formulary. Members may also access the
fied in this section, are prescribed by a physician                Formulary through the Blue Shield of California
or other licensed health care provider within the                  Web site at http://www.blueshieldca.com.
scope of his or her license as long as the pre-
scriber is a Plan provider, are obtained from a                    Benefits may be provided for non-Formulary
participating pharmacy, and are listed in the                      drugs subject to higher copayments.
Drug Formulary. Drug coverage is based on the
use of Blue Shield’s Outpatient Drug Formulary,                    Definitions
which is updated on an ongoing basis by Blue                       Brand Name Drugs - FDA approved drugs
Shield's Pharmacy and Therapeutics Committee.                      under patent to the original manufacturer and
Non-Formulary drugs may be covered subject                         only available under the original manufacturer's
to higher copayments. Selected drugs and drug                      branded name.
dosages and most home self-administered in-
jectables require prior authorization by Blue                      Drugs - (1) drugs which are approved by the
Shield for medical necessity, appropriateness of                   Food and Drug Administration (FDA), requir-
therapy or when effective, lower cost alterna-                     ing a prescription either by federal or California
tives are available (the more costly alternative                   law, (2) insulin, and disposable hypodermic insu-
will be authorized when medically necessary).                      lin needles and syringes, (3) pen delivery systems
                                                                   for the administration of insulin as determined
Smoking cessation drugs are covered for Mem-                       by Blue Shield to be medically necessary,
bers after completion of smoking cessation                         (4) diabetic testing supplies (including lancets,
classes or programs. This benefit is limited to                    lancet puncture devices, and blood and ketone
one course of treatment per calendar year.                         urine testing strips and test tablets in medically
Members may contact their medical group or                         appropriate quantities for the monitoring and
IPA for information about these classes and                        treatment of insulin dependent, non-insulin de-
programs. Blue Shield will reimburse the cost of                   pendent and gestational diabetes), (5) oral con-
the drugs only, minus the copayment, after re-                     traceptives and diaphragms, and (6) inhalers and
ceiving a copy of a certificate of completion for                  inhaler spacers for the management and treat-
a smoking cessation class or program. Partici-                     ment of asthma. Note: No prescription is nec-
pants are responsible for the cost of the smok-                    essary to purchase the items shown in (2), (3)
ing cessation class or program. If you have a                      and (4); however, in order to be covered these
question about the smoking cessation benefit,                      items must be ordered by your provider.
you should call Blue Shield Member Services at
1-800-334-5847.                                                    Formulary - a comprehensive list of drugs
                                                                   maintained by Blue Shield's Pharmacy and
Outpatient Drug Formulary                                          Therapeutics Committee for use under the Blue
Medications are selected for inclusion in Blue                     Shield Prescription Drug Program, which is de-
Shield’s Outpatient Drug Formulary based on                        signed to assist physicians in prescribing drugs
safety, efficacy, FDA bioequivalency data and                      that are medically necessary and cost effective.
then cost. New drugs and clinical data are re-                     The Formulary is updated periodically. If not
viewed regularly to update the Formulary. Drugs

                                                              87
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
otherwise excluded, the Formulary includes all            provide covered home self-administered in-
generic drugs.                                            jectables. These pharmacies offer 24-hour clini-
                                                          cal services and provide prompt home delivery
Generic Drugs - drugs that (1) are approved by            of home self-administered injectables.
the FDA as a therapeutic equivalent to the
brand name drug, (2) contain the same active              To select a specialty pharmacy, the Member may
ingredient as the brand name drug, and (3) cost           go to http://www.blueshieldca.com or call
less than the brand name drug equivalent.                 Member Services at 1-800-334-5847.

Home Self-Administered Injectables - home                 Obtaining Outpatient Prescription
self-administered injectables are defined as those        Drugs at a Participating Pharmacy
drugs which are medically necessary, adminis-             1. To obtain drugs at a participating pharmacy,
tered more often than once a month by patient                the Member must present his Blue Shield
or family member, administered subcutaneously                Identification Card. Note: Except for cov-
or intramuscularly, deemed safe for self-                    ered emergencies, claims for drugs obtained
administration as determined by Blue Shield’s                without using the Identification Card will be
Pharmacy and Therapeutics Committee, prior                   denied.
authorized by Blue Shield and obtained from a
Blue Shield specialty pharmacy. Intravenous               2. Benefits are provided for home self-
(IV) medications (i.e. those medications admin-              administered injectables only when obtained
istered directly into a vein) are not considered             from a Blue Shield specialty pharmacy, ex-
home self-administered injectable drugs. Home                cept in the case of an emergency. In the
self-administered injectables are listed in Blue             event of an emergency, covered home self-
Shield’s Outpatient Drug Formulary.                          administered injectables that are needed
                                                             immediately may be obtained from any par-
Home self-administered injectables purchased                 ticipating pharmacy, or, if necessary from a
from other pharmacies are not covered.                       non-participating pharmacy.
Non-Formulary Drugs - drugs determined by                 3. The Member is responsible for paying the
Blue Shield's Pharmacy and Therapeutics Com-                 applicable copayment for each covered new
mittee as being duplicative or as having pre-                and refill prescription drug. The pharmacist
ferred Formulary drug alternatives available.                will collect from the Member the applicable
Benefits may be provided for non-Formulary                   copayment at the time the drugs are ob-
drugs and are always subject to the non-                     tained.
Formulary copayment.
                                                                 Copayment: $5 generic, $15 brand
Non-Participating Pharmacy - a pharmacy                          name*, $45 non-Formulary per pre-
which does not participate in the Blue Shield                    scription for the amount prescribed
Pharmacy Network.                                                not to exceed a 30-day supply.

Participating Pharmacy - a pharmacy which                    *For diabetic supplies (including disposable
participates in the Blue Shield Pharmacy Net-                insulin needles and syringes), diaphragms
work. These participating pharmacies have                    and smoking cessation therapy drugs, the
agreed to a contracted rate for covered prescrip-            Formulary brand name copayment applies.
tions for Blue Shield Members.
                                                             If the participating pharmacy contracted rate
To select a participating pharmacy, the Member               charged by the participating pharmacy is less
may go to http://www.blueshieldca.com or call                than or equal to the Member copayment,
Member Services at 1-800-334-5847.                           the Member will only be required to pay the
                                                             participating pharmacy contracted rate.
Specialty Pharmacy Network - select partici-
pating pharmacies contracted by Blue Shield to

                                                     88
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
   Prescription drugs administered in a physi-             gency, the submission of a Prescription
   cian’s office, except immunizations, are cov-           Drug Claim is required. Claim forms are
   ered by the $10 copayment for the office                available by contacting Member Services.
   visit and do not require another copayment.             Submit completed Prescription Drug Claim
                                                           form noting "Emergency Request" on form
   Some prescriptions are limited to a maxi-               to Blue Shield Pharmacy Services, P.O. Box
   mum allowable quantity based on medical                 7168, San Francisco, CA 94120. Claims
   necessity and appropriateness of therapy as             must be received within 1 year from the
   determined by Blue Shield’s Pharmacy and                date of service to be considered for pay-
   Therapeutics Committee.                                 ment. Reimbursement for covered emer-
                                                           gency claims will be based upon the
4. If the Member requests a brand name drug                purchase price of covered prescription
   when a generic drug equivalent is available,            drug(s) less any applicable copayment(s).
   the Member is responsible for paying the
   difference between the participating phar-           Obtaining Outpatient Prescription
   macy contracted rate for the brand name              Drugs Through the Mail Service
   drug and its generic drug equivalent, as well        Prescription Drug Program
   as the applicable generic drug copayment.            1. For the Member’s convenience, when drugs
                                                           have been prescribed for a chronic condi-
5. If the prescription specifies a brand name
                                                           tion and the Member's medication dosage
   drug and the prescribing provider has writ-
                                                           has been stabilized, he may obtain the drug
   ten “Dispense As Written” or “Do Not
                                                           through Blue Shield's Mail Service Prescrip-
   Substitute” on the prescription, or if a ge-
                                                           tion Drug Program. Prior to using this Mail
   neric drug equivalent is not available, the
                                                           Service Program, the Member must have re-
   Member is responsible for paying the appli-
                                                           ceived the same medication and dosage
   cable brand name drug copayment.
                                                           through the Blue Shield Pharmacy Network
                                                           for at least 2 months. Blue Shield will pro-
6. If the provider determines that use of a
                                                           vide mail order forms and information at
   Formulary alternative is not appropriate for
                                                           the time of enrollment. The Member should
   the Member, the provider may request ap-
                                                           submit the applicable copayment, an order
   proval of a medically appropriate non-
                                                           form and his Blue Shield Member number
   Formulary drug by Blue Shield. See the sec-
                                                           to the address indicated on the mail order
   tion below on Approval of Non-Formulary
                                                           envelope. Be sure to send in your refill re-
   Drugs for information on the approval
                                                           quest approximately 3 weeks before your
   process. If Blue Shield approves this re-
                                                           supply runs out. Members should allow 14
   quest, the copayment for this non-
                                                           days to receive the drug. The Member’s
   Formulary drug is $30.
                                                           provider must indicate a prescription quan-
7. The Member is responsible for paying a co-              tity which is equal to the amount to be dis-
   payment of $30 for each prescription for                pensed. Home self-administered injectables,
   home self-administered injectables, includ-             except for insulin, are not available through
   ing any combination kit or package contain-             the Mail Service Prescription Drug Program.
   ing both oral and home self-administered
                                                        2. The Member is responsible for paying the
   injectable drugs.
                                                           applicable copayment for each covered new
8. Drugs obtained at a non-participating                   and refill prescription drug. Copayments will
   pharmacy are not covered, unless medically              be tracked for the Member.
   necessary for a covered emergency, includ-
                                                               Copayment: $10 generic, $25 brand
   ing drugs for emergency contraception. If
                                                               name*, $75 non-Formulary per pre-
   the Member must obtain drugs from a non-                    scription not to exceed a 90-day sup-
   participating pharmacy due to an emer-                      ply; $1,000 out-of-pocket annual

                                                   89
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
       maximum, then no charge. If the                  Approval of Non-Formulary Drugs
       Member’s provider indicates a pre-               A non-Formulary drug may be covered at a
       scription quantity of less than a 90-day         lower copayment as described above. Your pro-
       supply, that amount will be dispensed            vider may request approval from Blue Shield
       and refill authorizations cannot be              Pharmacy Services. After all necessary docu-
       combined to reach a 90-day supply.
                                                        mentation is available from your provider, ap-
                                                        proval or denial will be provided to your
   *For diabetic supplies (including disposable
                                                        provider within 2 working days of the request.
   insulin needles and syringes), the Formulary
                                                        Non-Formulary drugs that are not specifically
   brand name copayment applies.
                                                        listed as exclusions herein may be considered for
   If the participating pharmacy contracted rate        approval in these situations:
   is less than or equal to the Member copay-
                                                        1. When no Formulary alternative is appropri-
   ment, the Member will only be required to
                                                           ate and the drug is considered to be medi-
   pay the participating pharmacy contracted
                                                           cally necessary for you, as determined by
   rate.
                                                           Blue Shield. Your provider may be required
3. If the Member requests a mail service brand             to submit persuasive evidence in the form
   name drug when a mail service generic drug              of studies, records or documents showing
   equivalent is available, the Member is re-              that use of the requested non-Formulary
   sponsible for the difference between the                drug over a Formulary drug is medically
   contracted rate for the mail service brand              necessary;
   name drug and its mail service generic drug
                                                        2. When you have failed treatment or have ex-
   equivalent, as well as the applicable mail
                                                           perienced adverse effects with the Formu-
   service generic drug copayment.
                                                           lary drug. Blue Shield will request your
4. If the prescription specifies a mail service            provider to provide clinical information that
   brand name drug and the prescribing pro-                documents treatment failure or adverse ef-
   vider has written “Dispense As Written” or              fects with a Formulary alternative;
   “Do Not Substitute” on the prescription, or
                                                        3. When your treatment is stable with a non-
   if a mail service generic drug equivalent is
                                                           Formulary drug and conversion to a Formu-
   not available, the Member is responsible for
                                                           lary drug would be medically inappropriate.
   paying the applicable mail service brand
   name drug copayment.                                 If, after review, it is determined that a Formu-
                                                        lary alternative in this instance is not appropriate
5. If the provider determines that use of a
                                                        for you, the non-Formulary drug will be ap-
   Formulary alternative is not appropriate for
                                                        proved and be covered at the lower copayment
   the Member, the provider may request ap-
                                                        of $30 at the participating pharmacy or $45
   proval of a medically appropriate non-
                                                        through mail service. If, however, it is deter-
   Formulary drug by Blue Shield. See the sec-
                                                        mined that the non-Formulary drug does not
   tion below on Approval of Non-Formulary
                                                        meet one of the three criteria described above,
   Drugs for information on the approval
                                                        then the non-Formulary drug will be covered at
   process. If Blue Shield approves this re-
                                                        the higher copayment of $45 at the participating
   quest, the copayment for this non-
                                                        pharmacy or $75 through mail service.
   Formulary drug is $45.

6. For information about the Mail Service Pre-          Exclusions
   scription Drug Program, the Member may               No benefits are provided under the Prescription
   refer to the mail service program brochure           Drugs benefit for the following (please note,
   for the phone number and a more detailed             certain services excluded below may be covered
   explanation or call Blue Shield Member Ser-          under other benefits/portions of this Evidence
   vices at 1-800-334-5847.                             of Coverage – you should refer to the applicable

                                                   90
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
section to determine if drugs are covered under          10. Injectable drugs which are not self- adminis-
that benefit):                                               tered. Other injectable medications may be
                                                             covered under Y. Additional Services;
1. Drugs obtained from a non-participating
   pharmacy, except for a covered emergency,             11. Appetite suppressants or drugs for body
   drugs for emergency contraception, and                    weight reduction except when medically
   drugs obtained outside of California which                necessary for the treatment of morbid obe-
   are related to an urgently needed service and             sity. In such cases the drug will be subject to
   for which a participating pharmacy was not                prior authorization from Blue Shield;
   reasonably accessible;
                                                         12. Drugs when prescribed for smoking cessa-
2. Any drug provided or administered while                   tion purposes, except as provided under this
   the Member is an inpatient, or in a pro-                  Section P.;
   vider's office (see A. Hospital Services and
   B. Physician Services);                               13. Compounded medications if: (1) there is a
                                                             medically appropriate Formulary alternative,
3. Take home drugs received from a hospital,                 or, (2) there are no FDA-approved indica-
   convalescent home, skilled nursing facility,              tions. Compounded medications that do not
   or similar facility (see A. Hospital Services             include at least one drug, as defined, are not
   and N. Skilled Nursing Facility Services);                covered;

4. Except as specifically listed as covered un-          14. Replacement of lost, stolen or destroyed
   der this Section P., drugs which can be ob-               prescription drugs;
   tained without a prescription or for which
   there is a non-prescription drug that is the          15. Drugs prescribed for treatment of dental
   identical chemical equivalent (i.e., same ac-             conditions. This exclusion shall not apply to
   tive ingredient and dosage) to a prescription             antibiotics prescribed to treat infection nor
   drug;                                                     to medications prescribed to treat pain.

5. Drugs for which the Member is not legally             Call Member Services at 1-800-334-5847 for fur-
   obligated to pay, or for which no charge is           ther information.
   made;
                                                         See the Grievance Process section of this Evi-
6. Drugs that are considered to be experimen-            dence of Coverage for information on filing a
   tal or investigational;                               grievance, your right to seek assistance from the
                                                         Department of Managed Health Care and your
7. Medical devices or supplies, except as spe-           rights to independent medical review.
   cifically listed as covered herein (see E. Du-
   rable Medical Equipment, Prostheses and               Q. Inpatient Mental Health and
   Orthoses and Other Services);                            Substance Abuse Services
                                                         Blue Shield of California’s MHSA administers
8. Drugs when prescribed for cosmetic pur-               and delivers the Plan’s mental health and sub-
   poses, including but not limited to drugs             stance abuse benefits. These services are pro-
   used to retard or reverse the effects of skin         vided through a unique network of MHSA
   aging or to treat hair loss;                          Participating Providers. All non-emergency
                                                         mental health and substance abuse services must
9. Dietary or nutritional products (see K.               be arranged through the MHSA. Also, all non-
   Home Health Care Services, PKU-Related                emergency mental health and substance abuse
   Formulas and Special Food Products, and               services must be prior authorized by the MHSA.
   Home Infusion Therapy);                               For prior authorization for mental health and



                                                    91
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
substance abuse services, Members should con-             2. Medically necessary outpatient psychiatric
tact the MHSA at 1-866-505-3409.                             care for the diagnosis and treatment of se-
                                                             vere mental illnesses of a Member of any
All non-emergency mental health and substance                age and of serious emotional disturbances of
abuse services must be obtained from MHSA                    a child. Intensive outpatient care and psy-
Participating Providers. (See the How to Use the             chological testing are covered under this
Plan section, the Mental Health and Substance                benefit.
Abuse Services paragraphs for more informa-
tion.)                                                            Copayment: $10 per visit.

Benefits are provided for the following medi-             3. Crisis intervention and treatment for sub-
cally necessary covered mental health and sub-               stance abuse on an outpatient basis as medi-
stance abuse services, subject to applicable                 cally appropriate. This benefit is limited to
copayments and charges in excess of any benefit              20 visits per calendar year.
maximums. Coverage for these services is sub-
ject to all terms, conditions, limitations and ex-                Copayment: $10 per visit.
clusions of the Agreement, to any conditions or
limitations set forth in the benefit description          4. Psychosocial Support
below, and to the Exclusions and Limitations
set forth in this booklet.                                    See the Mental Health and Substance Abuse
                                                              Services paragraphs under the How to Use
Inpatient hospital and professional services in               the Plan section for information on psycho-
connection with hospitalization or psychiatric                social support services available under
partial hospitalization, for the treatment of men-            Lifepath Advisers.
tal illness (including treatment of severe mental
illnesses of a Member of any age and of serious                   Copayment: No charge.
emotional disturbances of a child), are covered.
All non-emergency mental health and substance             S. Medical Treatment of the Teeth,
abuse services must be prior authorized by the               Gums, Jaw Joints or Jaw Bones
MHSA and obtained from MHSA Participating                 Hospital and professional services provided for
Providers. Residential care is not covered.               conditions of the teeth, gums or jaw joints and
                                                          jaw bones, including adjacent tissues are a bene-
See Section A. for information on medically               fit only to the extent that they are provided for:
necessary inpatient substance abuse detoxifica-
tion.                                                     1. The treatment of tumors of the gums;

        Copayment: No charge.                             2. The treatment of damage to natural teeth
                                                             caused solely by an accidental injury is lim-
R. Outpatient Mental Health and                              ited to medically necessary services until the
   Substance Abuse Services                                  services result in initial, palliative stabiliza-
1. Medically necessary outpatient psychiatric                tion of the Member as determined by the
   care for other than severe mental illnesses or            Plan;
   serious emotional disturbances of a child.
   This benefit is limited to a combined maxi-                Dental services provided after initial medical
   mum of 20 visits for diagnosis and treat-                  stabilization, prosthodontics, orthodontia
   ment in any calendar year. Intensive                       and cosmetic services are not covered. This
   outpatient treatment is not covered under                  benefit does not include damage to the
   this benefit.                                              natural teeth that is not accidental (e.g., re-
                                                              sulting from chewing or biting).
        Copayment: $20 per visit.



                                                     92
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
3. Medically necessary non-surgical treatment            T. Special Transplant Benefits
   (e.g., splint and physical therapy) of Tem-           Benefits are provided for certain procedures
   poromandibular Joint Syndrome (TMJ);                  listed below only if: (1) performed at a Trans-
                                                         plant Network Facility approved by Blue Shield
4. Surgical and arthroscopic treatment of TMJ            of California to provide the procedure, (2) prior
   if prior history shows conservative medical           authorization is obtained, in writing, from the
   treatment has failed;                                 Blue Shield Corporate Medical Director, and
                                                         (3) the recipient of the transplant is a Member.
5. Medically necessary treatment of maxilla and
   mandible (jaw joints and jaw bones); or               The Blue Shield Corporate Medical Director
                                                         shall review all requests for prior authorization
6. Orthognathic surgery (surgery to reposition           and shall approve or deny benefits, based on the
   the upper and/or lower jaw) which is medi-            medical circumstances of the patient, and in ac-
   cally necessary to correct skeletal deformity.        cordance with established Blue Shield medical
                                                         policy. Failure to obtain prior written authoriza-
        Copayment: See applicable copay-                 tion as described above and/or failure to have
        ments for Physician Services and Hos-
                                                         the procedure performed at a Blue Shield ap-
        pital Services.
                                                         proved Transplant Network Facility will result
This benefit does not include:                           in denial of claims for this benefit.

1. Services performed on the teeth, gums                 Pre-transplant evaluation and diagnostic tests,
   (other than tumors) and associated perio-             transplantation and follow-ups will be allowed
   dontal structures, routine care of teeth and          only at a Blue Shield approved Transplant Net-
   gums, diagnostic services, preventive or pe-          work       Facility. Non-acute/non-emergency
   riodontic services, dental orthosis and pros-         evaluations, transplantations and follow-ups at
   thesis, including hospitalization incident            facilities other than a Blue Shield Transplant
   thereto;                                              Network Facility will not be approved. Evalua-
                                                         tion of potential candidates at a Blue Shield
2. Orthodontia (dental services to correct ir-           Transplant Network Facility is covered subject
   regularities or malocclusion of the teeth) for        to prior authorization. In general, more than
   any reason, including treatment to alleviate          one evaluation (including tests) within a short
   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.


                                                    93
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
5. Human kidney and pancreas transplants in                   b. insulin pumps and all related necessary
   combination (kidney only transplants are                      supplies;
   covered under Section U.);
                                                              c. podiatric devices to prevent or treat dia-
6. Human bone marrow transplants, including                      betes-related complications, including ex-
   autologous bone marrow transplantation or                     tra-depth orthopedic shoes;
   autologous peripheral stem cell transplanta-
   tion used to support high-dose chemother-                  d. visual aids, excluding eyewear and/or
   apy when such treatment is medically                          video-assisted devices, designed to assist
   necessary and is not experimental or investi-                 the visually impaired with proper dosing
   gational;                                                     of insulin;
                                                              e. for coverage of diabetic testing supplies
7. Pediatric human small bowel transplants;
                                                                 including blood and urine testing strips
                                                                 and test tablets, lancets and lancet punc-
8. Pediatric and adult human small bowel and
                                                                 ture devices and pen delivery systems for
   liver transplants in combination.
                                                                 the administration of insulin, see Section
Reasonable charges for services incident to ob-                  P.
taining the transplanted material from a living                   Copayment: No charge.
donor or an organ transplant bank will be cov-
ered.                                                     2. Diabetes Self-Management Training
        Copayment: Physician Services and                     Diabetes outpatient self-management train-
        Hospital Services copayments apply.                   ing, education and medical nutrition therapy
                                                              that is medically necessary to enable a
U. Organ Transplant Benefits                                  Member to properly use the diabetes-related
Hospital and professional services provided in                devices and equipment and any additional
connection with human organ transplants are a                 treatment for these services if directed or
benefit to the extent that they are provided in               prescribed by the Member’s Personal Physi-
connection with the transplant of a cornea, kid-              cian and authorized. These benefits shall in-
ney, or skin, and the recipient of such transplant            clude, but not be limited to, instruction that
is a Member.                                                  will enable diabetic patients and their fami-
                                                              lies to gain an understanding of the diabetic
Services incident to obtaining the human organ                disease process, and the daily management
transplant material from a living donor or an or-             of diabetic therapy, in order to thereby
gan transplant bank will be covered.                          avoid frequent hospitalizations and compli-
                                                              cations.
        Copayment: Physician Services and
        Hospital Services copayments apply.                       Copayment: $10 per visit.
V. Diabetes Care                                          W. Reconstructive Surgery
1. Diabetic Equipment                                     Medically necessary services in connection with
                                                          reconstructive surgery to correct or repair ab-
    Benefits are provided for the following de-
                                                          normal structures of the body and which result
    vices and equipment, including replacement
                                                          in more than a minimal improvement in func-
    after the expected life of the item and when
                                                          tion or appearance (including congenital anoma-
    medically necessary, for the management
                                                          lies) are covered. In accordance with the
    and treatment of diabetes when medically
                                                          Women’s Health & Cancer Rights Act, surgi-
    necessary and authorized:
                                                          cally implanted and other prosthetic devices (in-
                                                          cluding prosthetic bras) and reconstructive
    a. blood glucose monitors, including those
                                                          surgery on either breast provided to restore and
       designed to assist the visually impaired;

                                                     94
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
achieve symmetry incident to a mastectomy are                  meaningful potential to benefit the Member;
covered. Surgery must be authorized as de-                     with a therapeutic intent; and
scribed herein. Any such services must be re-
ceived while the Plan is in force with respect to          2. The Member’s treating physician recom-
the Member. Benefits will be provided in accor-               mends participation in the clinical trial; and
dance with guidelines established by the Plan
and developed in conjunction with plastic and              3. The hospital and/or physician conducting
reconstructive surgeons.                                      the clinical trial is a Plan provider, unless the
                                                              protocol for the trial is not available through
No benefits will be provided for the following                a Plan provider.
surgeries or procedures unless determined by
Blue Shield to be medically necessary to correct           Services for routine patient care will be paid on
or repair abnormal structures of the body                  the same basis and at the same benefit levels as
caused by congenital defects, developmental ab-            other covered services.
normalities, trauma, infection, tumors, or dis-
ease, and which will result in more than minimal           Routine patient care consists of those services
improvement in function or appearance:                     that would otherwise be covered by the Plan if
                                                           those services were not provided in connection
1. Surgery to excise, enlarge, reduce, or change           with an approved clinical trial, but does not in-
   the appearance of any part of the body;                 clude:

2. Surgery to reform or reshape skin or bone;              1. Drugs or devices that have not been ap-
                                                              proved by the federal Food and Drug Ad-
3. Surgery to excise or reduce skin or connec-                ministration (FDA);
   tive tissue that is loose, wrinkled, sagging, or
   excessive on any part of the body;                      2. Services other than health care services,
                                                              such as travel, housing, companion expenses
4. Hair transplantation; and                                  and other non-clinical expenses;

5. Upper eyelid blepharoplasty without docu-               3. Any item or service that is provided solely
   mented significant visual impairment or                    to satisfy data collection and analysis needs
   symptomatology.                                            and that is not used in the clinical manage-
                                                              ment of the patient;
This limitation shall not apply when breast re-
construction is performed subsequent to a                  4. Services that, except for the fact that they
medically necessary mastectomy, including sur-                are being provided in a clinical trial, are spe-
gery on either breast to achieve or restore sym-              cifically excluded under the Plan;
metry.
                                                           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;

                                                      95
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
   c. the United States Department of De-                  the member. AFHC is coordinated by call-
      fense;                                               ing 1-800-334-5847.
   d. the United States Veterans’ Administra-              AFHC also offers a special short-term ser-
      tion; or                                             vice which is available to members requiring
                                                           specific follow-up treatment. This option is
2. Involves a drug that is exempt under federal            particularly beneficial for members who will
   regulations from a new drug application.                be out-of-state on a short-term basis but re-
                                                           quire special treatment.
       Copayment: Physician Services and
       Hospital Services copayments apply.
                                                        4. Hearing Aid Services
Y. Additional Services                                     a. Audiological Evaluation. To measure the
1. Personal Health Management Program                         extent of hearing loss and a hearing aid
                                                              evaluation to determine the most appro-
   Health education and health promotion ser-                 priate make and model of hearing aid.
   vices provided by Blue Shield’s Center for
   Health Improvement offer a variety of well-                 Copayment: No charge. Evaluation is
   ness resources including, but not limited to:               in addition to the $1,000 maximum al-
   a member newsletter and a prenatal health                   lowed every 36 months for both ears
   education program.                                          for the hearing aid and ancillary
                                                               equipment.
       Copayment: No charge.
                                                           b. Hearing Aid. Monaural or binaural in-
2. Injectable Medications                                     cluding ear mold(s), the hearing aid in-
                                                              strument, the initial battery, cords and
   Injectable medications approved by the                     other ancillary equipment. Includes visits
   FDA are covered for the medically neces-                   for fitting, counseling, adjustments, re-
   sary treatment of medical conditions when                  pairs, etc. at no charge for a 1-year pe-
   prescribed or authorized by the Personal                   riod following the provision of a covered
   Physician or as described herein. See Section              hearing aid.
   P. for information on insulin and home self-
   administered injectables coverage and co-                  Excludes the purchase of batteries or
   payment.                                                   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.
   ID card. Membership eligibility is applicable
   to spouses, domestic partners and depend-                   Limitations: Up to maximum of $1,000
   ents who are away from home for at least 90                 per Member every 36 months for both
   days, or to members who are away from                       ears for the hearing aid instrument,
   home for at least 90 days but not more than                 and ancillary equipment.
   180 days. There is no additional charge to
                                                           To receive these services, you may either
                                                           contact your Personal Physician to obtain a

                                                   96
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    referral or self-refer to an Access+ Specialist            • Lower eyelid blepharoplasty;
    as described in the How to Use the Plan                    • Spider veins;
    section.                                                   • Procedures to smooth the skin (i.e.,
                                                                 chemical face peels, laser resurfacing,
5. Biofeedback                                                   and abrasive procedures);
                                                               • Hair removal by electrolysis or other
    Biofeedback therapy is covered only when it                  means; and
    is reasonable and necessary for the individ-
                                                               • Reimplantation of breast implants
    ual patient for muscle re-education of spe-
                                                                 originally provided for cosmetic aug-
    cific muscle groups or for treating
                                                                 mentation;
    pathological muscle abnormalities of spas-
    ticity, incapacitating muscle spasm, or weak-          4. Custodial or Domiciliary Care. For or in-
    ness, and more conventional treatments                    cident to services rendered in the home or
    (heat, cold, massage, exercise, support) have             hospitalization or confinement in a health
    not been successful. This therapy is not                  facility primarily for custodial, maintenance
    covered for treatment of ordinary muscle                  or domiciliary care, except as provided un-
    tension states or for psychosomatic condi-                der O.; or rest;
    tions.
                                                           5. Dental Care, Dental Appliances. For den-
        Copayment: No charge.                                 tal care or services incident to the treatment,
                                                              prevention or relief of pain or dysfunction
6. Chiropractic Care
                                                              of the temporomandibular joint and/or
    Manipulation of the spine to correct a sub-               muscles of mastication, except as specifically
    luxation, upon referral from your Personal                provided under S.; for or incident to ser-
    Physician, when provided by chiropractors                 vices and supplies for treatment of the teeth
    or other qualified providers.                             and gums (except for tumors) and associ-
                                                              ated periodontal structures, including but
        Copayment: $10 per visit.                             not limited to diagnostic, preventive, ortho-
                                                              dontic, and other services such as dental
Exclusions and Limitations                                    cleaning, tooth whitening, x-rays, topical
                                                              fluoride treatment except when used with
General Exclusions and Limitations
                                                              radiation therapy to the oral cavity, fillings
Unless exceptions to the following exclusions                 and root canal treatment; treatment of
are specifically made elsewhere in the Agree-                 periodontal disease or periodontal surgery
ment, no benefits are provided for services                   for inflammatory conditions; tooth extrac-
which are:                                                    tion; dental implants; braces, crowns, dental
                                                              orthoses and prostheses; except as specifi-
1. Acupuncture. For or incident to acupunc-
                                                              cally provided under A. and S.;
   ture;
                                                           6. Experimental or Investigational Procedures.
2. Behavioral Problems. For learning dis-
                                                              Experimental or investigational medicine,
   abilities or behavioral problems;
                                                              surgery or other experimental or investiga-
3. Cosmetic Surgery. For cosmetic surgery,                    tional health care procedures as defined, ex-
   or any resulting complications, except medi-               cept for services for Members who have
   cally necessary services to treat complica-                been accepted into an approved clinical trial
   tions of cosmetic surgery (e.g., infections or             for cancer as provided under X.;
   hemorrhages) will be a benefit, but only
                                                               See section entitled “External Independent
   upon review and approval by a Blue Shield
                                                               Medical Review” for information concern-
   physician consultant. Without limiting the
                                                               ing the availability of a review of services
   foregoing, no benefits will be provided for
                                                               denied under this exclusion.
   the following surgeries or procedures:

                                                      97
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
7. Eye Surgery. For surgery to correct refrac-                 tilization (except for artificial insemination),
   tive error (such as but not limited to radial               services or medications to treat low sperm
   keratotomy, refractive keratoplasty), lenses                count or services incident to or resulting
   and frames for eyeglasses, contact lenses,                  from procedures for a surrogate mother
   except as provided under E., and video-                     who is otherwise not eligible for covered
   assisted visual aids or video magnification                 pregnancy and maternity care under a Blue
   equipment for any purpose;                                  Shield of California health plan;

8. Foot Care. For routine foot care, including             13. Learning Disabilities. For testing for in-
   callus, corn paring or excision and toenail                 telligence or learning disabilities;
   trimming (except as may be provided
   through a participating hospice agency);                14. Limited or Excluded Services. Benefits
   treatment (other than surgery) of chronic                   for services limited or excluded in your
   conditions of the foot, including but not                   HMO health service plan; however, drugs
   limited to weak or fallen arches, flat or pro-              customarily provided by dentists and oral
   nated foot, pain or cramp of the foot, bun-                 surgeons, or customarily provided for nerv-
   ions, muscle trauma due to exertion or any                  ous or mental disorders, or incident to
   type of massage procedure on the foot; spe-                 pregnancy, or customarily provided for sub-
   cial footwear (e.g., non-custom made or                     stance abuse, or incident to physical therapy
   over-the-counter shoe inserts or arch sup-                  are not excluded;
   ports), except as specifically provided under
   E. and V.;                                              15. Miscellaneous Equipment. For orthope-
                                                               dic shoes except as provided under V., envi-
9. Genetic Testing. For genetic testing except                 ronmental control equipment, generators,
   as described under D. and F.;                               exercise equipment, self-help/educational
                                                               devices, vitamins, any type of communica-
10. Home Monitoring Equipment. For home                        tor, voice enhancer, voice prosthesis, elec-
    testing devices and monitoring equipment,                  tronic voice producing machine, or any
    except for use of the peak flow monitor for                other language assistance devices, except as
    self-management of asthma, the glucose                     provided under E. and comfort items;
    monitor for self-management of diabetes
    and the apnea monitor for management of                16. Nutritional and Food Supplements. For
    newborn apnea when authorized as durable                   prescription or non-prescription nutritional
    medical equipment;                                         and food supplements except as provided
                                                               under K.;
11. Infertility Reversal. For or incident to the
    treatment of infertility or any form of as-            17. Organ Transplants. Incident to an organ
    sisted reproductive technology, including                  transplant, except as provided under T. and
    but not limited to the reversal of a vasec-                U.;
    tomy or tubal ligation, or any resulting com-
    plications, except for medically necessary             18. Over-the-Counter Medical Equipment
    treatment of medical complications;                        or Supplies. For non-prescription (over-
                                                               the-counter) medical equipment or supplies
12. Infertility Services. For any services related             that can be purchased without a licensed
    to assisted reproductive technology, includ-               provider's prescription order, even if a li-
    ing but not limited to the harvesting or                   censed provider writes a prescription order
    stimulation of the human ovum, ovum                        for a non-prescription item, except as spe-
    transplants, in vitro fertilization, Gamete In-            cifically provided under E., K., O. and V.;
    trafallopian Transfer (GIFT) procedure, Zy-
    gote Intrafallopian Transfer (ZIFT)                    19. Over-the-Counter Medications. For over-
    procedure or any other form of induced fer-                the-counter medications not requiring a pre-


                                                      98
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    scription, except as provided for smoking                 is another more appropriate surgical proce-
    cessation drugs;                                          dure that is approved by a Blue Shield phy-
                                                              sician consultant, or (2) when the surgery or
20. Pain Management. For or incident to                       procedure offers only a minimal improve-
    hospitalization or confinement in a pain                  ment in function or in the appearance of the
    management center to treat or cure chronic                enrollees, e.g., spider veins, or (3) as limited
    pain, except as may be provided through a                 under W.;
    participating hospice agency and except as
    medically necessary;                                  28. Services by Close Relatives. Services per-
                                                              formed by a close relative or by a person
21. Penile Implant. For penile implant devices                who ordinarily resides in the Member’s
    and surgery, and any related services except              home;
    for any resulting complications and medi-
    cally necessary services as provided under            29. Sex Transformations. For transgender or
    W.;                                                       gender dysphoria conditions, including but
                                                              not limited to, intersex surgery (transsexual
22. Personal Comfort Items. Convenience                       operations), or any related services, or any
    items such as telephones, TVs, guest trays,               resulting medical complications, except for
    and personal hygiene items;                               treatment of medical complications that is
                                                              medically necessary;
23. Physical Examinations. For physical ex-
    ams required for licensure, employment, or            30. Sexual Dysfunctions. For or incident to
    insurance unless the examination corre-                   sexual dysfunctions and sexual inadequacies,
    sponds to the schedule of routine physical                except as provided for treatment of organi-
    examinations provided under C.;                           cally based conditions;

24. Prescription Orders. Prescription orders              31. Speech Therapy. For or incident to speech
    or refills which exceed the amount specified              therapy, speech correction or speech pa-
    in the prescription, or prescription orders or            thology or speech abnormalities that are not
    refills dispensed more than a year from the               likely the result of a diagnosed, identifiable
    date of the original prescription.                        medical condition, injury or illness, except
                                                              as specifically provided under K., M. and
    Prescription orders or refills in quantities              O.;
    exceeding a 30-day supply, except for mail
    order.                                                32. Spinal Manipulation. For spinal manipula-
                                                              tion or adjustment, except as covered by
    Prescription orders or refills which are equal            Medicare;
    to or less than the amount of your copay-
    ment.                                                 33. Therapeutic Devices. Devices or appara-
                                                              tuses, regardless of therapeutic effect (e.g.,
25. Private Duty Nursing. In connection with                  hypodermic needles and syringes, except as
    private duty nursing, except as provided un-              needed for insulin and covered injectable
    der A., K. and O.;                                        medication), support garments and similar
                                                              items;
26. Reading/Vocational Therapy. For or in-
    cident to reading therapy; vocational, educa-         34. Transportation Services. For transporta-
    tional, recreational, art, dance or music                 tion services other than provided for under
    therapy; weight control or exercise pro-                  H.;
    grams;
                                                          35. Unapproved Drugs/Medicines. Drugs
27. Reconstructive Surgery. For reconstruc-                   and medicines which cannot be lawfully
    tive surgery and procedures: (1) where there              marketed without approval of the U.S. Food

                                                     99
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    and Drug Administration (FDA); however,                Medical Necessity Exclusion
    drugs and medicines which have received                All services must be medically necessary. The
    FDA approval for marketing for one or                  fact that a physician or other provider may pre-
    more uses will not be denied on the basis              scribe, order, recommend, or approve a service
    that they are being prescribed for an off-             or supply does not, in itself, make it medically
    label use if the conditions set forth in Cali-         necessary, even though it is not specifically listed
    fornia Health & Safety Code Section                    as an exclusion or limitation. Blue Shield may
    1367.21 have been met;                                 limit or exclude benefits for services which are
                                                           not medically necessary.
36. Unauthorized Non-Emergency Services.
    For unauthorized non-emergency services;               Limitations for Duplicate Coverage
                                                           In the event that you are covered under the Plan
37. Unauthorized Treatment. Not provided,                  and are also entitled to benefits under any of the
    prescribed, referred, or authorized as de-             conditions listed below, Blue Shield’s liability for
    scribed herein except for Access+ Specialist           services (including room and board) provided to
    visits, OB/GYN services provided by an                 the Member for the treatment of any one illness
    obstetrician/gynecologist or a family prac-            or injury shall be reduced by the amount of
    tice physician within the same medical                 benefits paid, or the reasonable value or the
    group or IPA as the Personal Physician,                amount of Blue Shield’s fee-for-service payment
    emergency services or urgent services as               to the provider, whichever is less, of the services
    provided under the Agreement provisions,               provided without any cost to you, because of
    when specific authorization has been ob-               your entitlement to such other benefits. This ex-
    tained in writing for such services as de-             clusion is applicable to benefits received from
    scribed herein, for mental health and                  any of the following sources:
    substance abuse services which must be ar-
    ranged through the MHSA or for hospice                 1. Benefits provided under Title 18 of the So-
    services received by a participating hospice              cial Security Act (“Medicare”). If a Member
    agency;                                                   receives services to which he is entitled un-
                                                              der Medicare and those services are also
38. Workers’ Compensation/Work-Related Injury.                covered under this Plan, the Plan provider
    For or incident to any injury or disease aris-            may recover the amount paid for the ser-
    ing out of, or in the course of, any employ-              vices under Medicare. This provision does
    ment for salary, wage or profit if such injury            not apply to Medicare Part D (outpatient
    or disease is covered by any workers’ com-                prescription drug) benefits.
    pensation law, occupational disease law or
    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
39. 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

                                                     100
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
reasonable charges for services rendered under             the subject of the Member’s dissatisfaction. See
this Plan.                                                 the Member Services Department section for in-
                                                           formation on the expedited decision process.
Claims and Services Review
Blue Shield reserves the right to review all               For all mental health and substance
claims and services to determine if any exclu-             abuse services
sions or other limitations apply. Blue Shield may          The Member, a designated representative, or a
use the services of physician consultants, peer            provider on behalf of the Member, may contact
review committees of professional societies or             the MHSA by telephone, letter or online to re-
hospitals and other consultants to evaluate                quest a review of an initial determination con-
claims.                                                    cerning a claim or service. Members may
                                                           contact the MHSA at the telephone number as
General Provisions                                         noted below. If the telephone inquiry to the
Grievance Process                                          MHSA’s Customer Service Department does
Blue Shield of California has established a griev-         not resolve the question or issue to the Mem-
ance procedure for receiving, resolving and                ber’s satisfaction, the Member may request a
tracking Members’ grievances with Blue Shield              grievance at that time, which the Customer Ser-
of California.                                             vice Representative will initiate on the Member’s
                                                           behalf.
For all services other than mental health
and substance abuse                                        The Member, a designated representative, or a
The Member, a designated representative, or a              provider on behalf of the Member, may also ini-
provider on behalf of the Member, may contact              tiate a grievance by submitting a letter or a com-
the Member Services Department by telephone,               pleted “Grievance Form.” The Member may
letter or online to request a review of an initial         request this form from the MHSA’s Customer
determination concerning a claim or service.               Service Department. If the Member wishes, the
Members may contact the Plan at the telephone              MHSA’s Customer Service staff will assist in
number as noted on the back cover of this                  completing the Grievance Form. Completed
booklet. If the telephone inquiry to Member                grievance forms must be mailed to the MHSA at
Services does not resolve the question or issue            the address provided below. The Member may
to the Member’s satisfaction, the Member may               also submit the grievance to the MHSA online
request a grievance at that time, which the                by visiting http://www.blueshieldca.com.
Member Services Representative will initiate on
                                                                           1-877-263-9952
the Member’s behalf.
                                                               U.S. Behavioral Health Plan, California
The Member, a designated representative, or a                         Attn: Customer Service
provider on behalf of the Member, may also ini-                          P. O. Box 880609
tiate a grievance by submitting a letter or a com-                     San Diego, CA 92168
pleted “Grievance Form.” The Member may
                                                           The MHSA will acknowledge receipt of a griev-
request this form from Member Services. The
                                                           ance within 5 calendar days. Grievances are re-
completed form should be submitted to Mem-
                                                           solved within 30 days. The grievance system
ber Services at the address as noted on the back
                                                           allows Members to file grievances for at least
cover of this booklet. The Member may also
                                                           180 days following any incident or action that is
submit the grievance online by visiting our web
                                                           the subject of the Member’s dissatisfaction. See
site at http://www.blueshieldca.com.
                                                           the Member Services Department section for in-
Blue Shield will acknowledge receipt of a griev-           formation on the expedited decision process.
ance within 5 calendar days. Grievances are re-
                                                           External Independent Medical Review
solved within 30 days. The grievance system
allows Members to file grievances for at least             If your grievance involves a claim or services for
180 days following any incident or action that is          which coverage was denied by Blue Shield or by

                                                     101
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
a contracting provider in whole or in part on the           Appeal Procedure Following Disposition
grounds that the service is not medically neces-            of Plan Grievance Procedure
sary or is experimental/investigational (including          If no resolution of your complaint is achieved
the external review available under the Fried-              by the internal grievance process described
man-Knowles Experimental Treatment Act of                   above, you have several options depending on
1996), you may choose to make a request to the              the nature of your complaint.
Department of Managed Health Care to have
the matter submitted to an independent agency               1. Eligibility Issues. Refer these matters di-
for external review in accordance with California              rectly to CalPERS. Contact CalPERS Office
law. You normally must first submit a grievance                of Employer and Member Health Services
to Blue Shield and wait for at least 30 days be-               at P.O. Box 942714, Sacramento, CA
fore you request external review; however, if                  94229-2714, Fax (916) 795-1277, or tele-
your matter would qualify for an expedited deci-               phone CalPERS Customer Service and
sion as described in the Member Services De-                   Education Division at 1-888 CalPERS (or
partment section or involves a determination                   888-225-7377), TTY 1-800-735-2929; (916)
that the requested service is experimen-                       795-3240.
tal/investigational, you may immediately request
an external review following receipt of notice of           2. Coverage Issues. A coverage issue con-
denial. You may initiate this review by complet-               cerns the denial or approval of health care
ing an application for external review, a copy of              services substantially based on a finding that
which can be obtained by contacting Member                     the provision of a particular service is in-
Services. The Department of Managed Health                     cluded or excluded as a covered benefit un-
Care will review the application and, if the re-               der this Evidence of Coverage booklet. It
quest qualifies for external review, will select an            does not include a plan or contracting pro-
external review agency and have your records                   vider decision regarding a disputed health
submitted to a qualified specialist for an inde-               care service.
pendent determination of whether the care is
medically necessary. You may choose to submit                   If you are dissatisfied with the outcome of
additional records to the external review agency                Blue Shield’s internal grievance process, you
for review. There is no cost to you for this ex-                may request an administrative review before
ternal review. You and your physician will re-                  the CalPERS Board of Administration, or
ceive copies of the opinions of the external                    you may choose Small Claims Court, if your
review agency. The decision of the external re-                 coverage dispute is within the jurisdictional
view agency is binding on Blue Shield; if the ex-               limits of Small Claims Court.
ternal reviewer determines that the service is
medically necessary, Blue Shield will promptly              3. Malpractice. You must proceed directly to
arrange for the service to be provided or the                  court.
claim in dispute to be paid. This external review
process is in addition to any other procedures or           4. Bad Faith. You must proceed directly to court.
remedies available to you and is completely vol-
untary on your part; you are not obligated to re-           5. Disputed Health Care Service Issue. A
quest external review. However, failure to                     disputed health care service issue concerns
participate in external review may cause you to                any health care service eligible for coverage
give up any statutory right to pursue legal action             and payment under this Evidence of Cover-
against Blue Shield regarding the disputed ser-                age booklet that has been denied, modified,
vice. For more information regarding the exter-                or delayed in whole or in part due to a find-
nal review process, or to request an application               ing that the service is not medically neces-
form, please contact Member Services.                          sary. A decision regarding a disputed health
                                                               care service relates to the practice of medi-
                                                               cine, and includes decisions as to whether a



                                                      102
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
    particular service is experimental or investi-         Department of Managed Health Care
    gational.                                              Review
                                                           The California Department of Managed Health
    If you are dissatisfied with the outcome of            Care is responsible for regulating health care
    Blue Shield’s internal grievance process, you          service plans. If you have a grievance against
    may request an administrative review before            your health plan, you should first telephone
    the CalPERS Board of Administration, or                your health plan at 1-800-334-5847 and use your
    you may proceed to court.                              health plan’s grievance process before contact-
                                                           ing the Department. Utilizing this grievance
CalPERS Administrative Appeal Process                      procedure does not prohibit any potential legal
Only issues of eligibility and coverage issues             rights or remedies that may be available to you.
which concern the denial or approval of health             If you need help with a grievance involving an
care services substantially based on a finding             emergency, a grievance that has not been satis-
that the provision of a particular service is in-          factorily resolved by your health plan, or a
cluded or excluded as a covered benefit under              grievance that has remained unresolved for
this Evidence of Coverage booklet may be ap-               more than 30 days, you may call the Department
pealed directly to CalPERS.                                for assistance. You may also be eligible for an
                                                           Independent Medical Review (IMR). If you are
CalPERS staff will conduct an administrative               eligible for IMR, the IMR process will provide
review upon your appeal of Blue Shield’s denial            an impartial review of medical decisions made
of coverage or the denial of a disputed health             by a health plan related to the medical necessity
care issue by the Department of Managed                    of a proposed service or treatment, coverage de-
Health Care. However, your written appeal must             cisions for treatments that are experimental or
be submitted to CalPERS within 30 days of the              investigational in nature and payment disputes
postmark date of Blue Shield’s letter of denial or         for emergency or urgent medical services. The
the Department of Managed Health Care’s de-                Department also has a toll-free telephone num-
termination of findings.                                   ber (1-888-HMO-2219) and a TDD line (1-877-
                                                           688-9891) for the hearing and speech impaired.
If the dispute remains unresolved during the               The          Department’s        Web         site
administrative review process, the matter may              (http://www.hmohelp.ca.gov) has complaint
then proceed to an administrative hearing. Dur-            forms, IMR application forms and instructions
ing the hearing, evidence and testimony will be            online.
presented to an Administrative Law Judge.
                                                           In the event that Blue Shield should cancel or
To file for an administrative review, contact              refuse to renew enrollment for you or your de-
CalPERS Office of Employer and Member                      pendents and you feel that such action was due
Health Services, P.O. Box 942714, Sacramento,              to health or utilization of benefits, you or your
CA 94229-2714, Fax (916) 795-1277, or tele-                dependents may request a review by the De-
phone CalPERS Customer Service and Educa-                  partment of Managed Health Care Director.
tion Division, 1-888 CalPERS (or 888-225-
7377), TTY 1-800-735-2929; (916) 795-3240.                 Matters of eligibility should be referred directly
                                                           to CalPERS - contact CalPERS Office of Em-
If you are covered by Medicare and Medicare                ployer and Member Health Services, P.O. Box
has made a decision regarding your appeal of a             942714, Sacramento, CA 94229-2714.
Medicare claim determination, you cannot ap-
peal the Medicare decision through the                     Alternate Arrangements
CalPERS Board of Administration.
                                                           Blue Shield will make a reasonable effort to se-
                                                           cure alternate arrangements for the provision of
                                                           care by another Plan provider without additional
                                                           expense to you in the event a Plan provider’s


                                                     103
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
contract is terminated, or a Plan provider is un-          viders from having to guess what you would
able or unwilling to provide care to you.                  have wanted. We suggest you set aside some
                                                           time to review and discuss your wishes with
If such alternate arrangements are not made                your Personal Physician and family members.
available, or are not deemed satisfactory to the
Board, then Blue Shield will provide all services          There are three types of advance directives to
and/or benefits of the Agreement to you on a               choose from. They are: (1) Durable Power of
fee-for-service basis (less any applicable copay-          Attorney for Health Care (DPAHC), (2) Living
ments), and the limitation contained herein with           Wills, and (3) Natural Death Act Declarations.
respect to use of a Plan provider shall be of no           In California, the preferred document is
force or effect.                                           DPAHC, which allows you to appoint an agent
                                                           (family, friend, or other person) whom you trust
Such fee-for-service arrangements shall continue           to make treatment decisions for you should
until any affected treatment plan has been com-            there come a time you are unable to make them
pleted or until such time as you agree to obtain           yourself. You can purchase the DPAHC from a
services from another Plan provider, your en-              stationery store or from the California Medical
rollment is terminated, or your enrollment is              Association.
transferred to another plan administered by the
Board, whichever occurs first. In no case, how-            You should provide copies of your completed
ever, will such fee-for-service arrangements con-          directive to:     (1) your Personal Physician,
tinue beyond the term of the Plan, unless the              (2) your agent, and (3) your family. Be sure to
Extension of Benefits provision applies to you.            keep a copy with you and take a copy to the
                                                           hospital if you are hospitalized for medical care.
Physician-Patient or Plan-Member
Relationship                                               Termination of Group Membership -
In the event that Blue Shield of California shall          Continuation of Coverage
be unable to establish satisfactory physician-             Termination of Benefits
patient or plan-member relationship with any               Coverage for you or your dependents terminates
member, after reasonable efforts to do so, then            at 12:01 a.m. Pacific Time on the earliest of
Blue Shield may either submit the matter for               these dates: (1) the date the group Agreement is
consideration under Blue Shield's grievance pro-           discontinued, (2) the last day of the month in
cedures or submit the matter for consideration             which the subscriber’s employment terminates,
by the Chief Executive Officer of CalPERS. In              unless a different date has been agreed to be-
any event, if it is determined that a satisfactory         tween Blue Shield and your employer, (3) the
physician-patient or plan-member relationship              end of the period for which the premium is
cannot be maintained, then the member shall be             paid, or (4) on the last day of the month in
provided with the opportunity to change en-                which you or your dependents become ineligi-
rollment to another plan.                                  ble. A spouse also becomes ineligible following
                                                           legal separation from the subscriber, entry of a
Advance Directives                                         final decree of divorce, annulment or dissolution
It is important that you know about your rights            of marriage from the subscriber. A domestic
to make health care decisions on your own be-              partner becomes ineligible upon termination of
half and to execute advance directives. An ad-             the domestic 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-

                                                     104
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
If you cease work because of retirement, disabil-           The group Agreement also may be cancelled by
ity, leave of absence, temporary layoff or termi-           CalPERS at any time provided written notice is
nation, see your employer about possibly                    given to Blue Shield to become effective upon
continuing group coverage. Also, see the Indi-              receipt, or on a later date as may be specified on
vidual Conversion Plan and COBRA and/or                     the notice.
Cal-COBRA provisions described in this book-
let for information on continuation of coverage.            Extension of Benefits
                                                            If a person becomes totally disabled while val-
If the subscriber no longer lives or works in the           idly covered under this Plan and continues to be
Plan service area, coverage will be terminated              totally disabled on the date group coverage ter-
for him and all his dependents. If a dependent              minates, Blue Shield will extend the benefits of
no longer lives or works in the Plan service area,          this Plan, subject to all limitations and restric-
then that dependent's coverage will be termi-               tions, for covered services and supplies directly
nated. (Special arrangements may be available               related to the condition, illness or injury causing
for dependents who are full-time students or do             such total disability until the first to occur of the
not live in the subscriber's home. Please contact           following: (1) the date the covered person is no
the Member Services Department to request a                 longer totally disabled, (2) 12:01 a.m. on the day
brochure which explains these arrangements.)                following a period of 12 months from the date
                                                            group coverage terminated, (3) the date on
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


                                                      105
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
events” to elect continuation for 18, 29, or 36              3. A dependent child ceases to be a dependent
months.                                                         child.

An eligible active or retired employee or his/her            4. The primary COBRA subscriber becomes
family member(s) is entitled to elect this cover-               entitled to Medicare.
age provided an election is made within 60 days
of notification of eligibility and the required              If elected, COBRA continuation coverage is ef-
premiums are paid. The benefits of the con-                  fective on the date coverage under the group
tinuation coverage are identical to the group                plan terminates.
plan and the cost of coverage shall be 102% of
the applicable group premiums rate. No em-                   The COBRA continuation coverage will remain
ployer contribution is available to cover the                in effect for the specified time, or until one of
premiums.                                                    the following events terminates the coverage:

Two “qualifying events” allow enrollees to re-               1. The termination of all employer provided
quest the continuation coverage for 18 months.                  group health plans, or
The Member's 18-month period may also be ex-
tended to 29 months if the Member was dis-                   2. The enrollee fails to pay the required pre-
abled on or before the date of termination or                   mium(s) on a timely basis, or
reduction in hours of employment, or is deter-
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.

                                                       106
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
COBRA enrollees must exhaust all the COBRA                 of services provided to the Member. The Mem-
coverage to which they are entitled before they            ber is required to:
can become eligible to continue coverage under
Cal-COBRA.                                                 1. Notify Blue Shield in writing of any actual
                                                              or potential claim or legal action which such
In no event will continuation of group coverage               Member anticipates bringing or has brought
under COBRA, Cal-COBRA or a combination                       against the third party arising from the al-
of COBRA and Cal-COBRA be extended for                        leged acts or omissions causing the injury or
more than 3 years from the date the qualifying                illness, not later than 30 days after submit-
event has occurred which originally entitled the              ting or filing a claim or legal action against
Member to continue group coverage under this                  the third party; and
Plan.
                                                           2. Agree to fully cooperate with Blue Shield,
Monthly rates for Cal-COBRA coverage shall be                 the Member’s designated medical group,
110% of the applicable group monthly rates.                   and the independent practice association to
                                                              execute any forms or documents needed to
Cal-COBRA enrollees must submit monthly                       assist them in exercising their equitable right
rates directly to Blue Shield. The initial monthly            to restitution or other available remedies;
rates must be paid within 45 days of the date the             and
Member provided written notification to the
Plan of the election to continue coverage and be           3. Provide Blue Shield, the Member’s desig-
sent to Blue Shield by first-class mail or other              nated medical group, and the independent
reliable means. The monthly rate payment must                 practice association with a lien in the
equal an amount sufficient to pay any required                amount of the reasonable costs of benefits
amounts that are due. Failure to submit the cor-              provided, calculated in accordance with
rect amount within the 45-day period will dis-                California Civil Code section 3040. The lien
qualify the Member from continuation coverage.                may be filed with the third party, the third
                                                              party’s agent or attorney, or the court unless
Blue Shield of California is responsible for noti-            otherwise prohibited by law.
fying COBRA enrollees of their right to possibly
continue coverage under Cal-COBRA at least 90              A Member’s failure to comply with 1. through
calendar days before their COBRA coverage will             3., above, shall not in any way act as a waiver,
end. The COBRA enrollee should contact Blue                release, or relinquishment of the rights of Blue
Shield for more information about continuing               Shield, the Member's designated medical group,
coverage. If the enrollee elects to apply for con-         or the independent practice association.
tinuation of coverage under Cal-COBRA, the
enrollee must notify Blue Shield at least 30 days          Further, if the Member receives services from a
before COBRA termination.                                  Plan hospital for such injuries, the hospital has
                                                           the right to collect from the Member the differ-
Payment by Third Parties                                   ence between the amount paid by Blue Shield
Third Party Recovery Process and                           and the hospital’s reasonable and necessary
the Member’s Responsibility                                charges for such services when payment or re-
If a Member is injured through the act or omis-            imbursement is received by the Member for
sion of another person (a “third party”), Blue             medical expenses. The Plan hospital’s right to
Shield, the Member’s designated medical group,             collect shall be in accordance with California
and the independent practice association shall,            Civil Code Section 3045.1.
with respect to services required as a result of
that injury, provide the benefits of the Plan and          Workers’ Compensation
have an equitable right to restitution or other            No benefits are provided for or incident to any
available remedy to recover the reasonable costs           injury or disease arising out of, or in the course
                                                           of, any employment for salary, wage or profit if

                                                     107
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
such injury or disease is covered by any workers’             birth) occurs earlier in a calendar year, shall de-
compensation law, occupational disease law or                 termine its benefits before a plan which covers
similar legislation.                                          that person as a dependent of a person whose
                                                              date of birth (excluding year of birth) occurs
However, if Blue Shield provides payment for                  later in a calendar year. If either plan does not
such services it will be entitled to establish a lien         have the provisions of this paragraph regarding
upon such other benefits up to the reasonable                 dependents, which results either in each plan de-
cash value of benefits provided by Blue Shield                termining its benefits before the other or in each
for the treatment of the injury or disease as re-             plan determining its benefits after the other, the
flected by the providers’ usual billed charges.               provisions of this paragraph shall not apply, and
                                                              the rule set forth in the plan which does not
Coordination of Benefits                                      have the provisions of this paragraph shall de-
When a person who is covered under this group                 termine the order of benefits.
Plan is also covered under another group plan,
or selected group, or blanket disability insurance            1. In the case of a claim involving expenses for
contract, or any other contractual arrangement                   a dependent child whose parents are sepa-
or any portion of any such arrangement                           rated or divorced, plans covering the child
whereby the members of a group are entitled to                   as a dependent shall determine their respec-
payment of or reimbursement for hospital or                      tive benefits in the following order: First,
medical expenses, such person will not be per-                   the plan of the parent with custody of the
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 patient as a dependent of                      regarding laid-off or retired employees,
a person whose date of birth (excluding year of                      which results in each plan determining its


                                                        108
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
       benefits after the other, then the provi-            If payments which should have been made un-
       sions of a. above shall not apply.                   der this Plan in accordance with these provi-
                                                            sions have been made by another Plan, Blue
If this Plan is the primary carrier with respect to         Shield may pay to the other Plan the amount
a covered person, then this Plan will provide its           necessary to satisfy the intent of these provi-
benefits without reduction because of benefits              sions. This amount shall be considered as bene-
available from any other plan.                              fits paid under this Plan. Blue Shield shall be
                                                            fully discharged from liability under this Plan to
When this Plan is secondary in the order of                 the extent of these payments.
payments, and Blue Shield is notified that there
is a dispute as to which plan is primary, or that           If payments have been made by Blue Shield in
the primary plan has not paid within a reason-              excess of the maximum amount of payment
able period of time, this Plan will provide the             necessary to satisfy these provisions, Blue Shield
benefits that would be due as if it were the pri-           shall have the right to recover the excess from
mary plan, provided that the covered person:                any person or other entity to or with respect to
(1) assigns to Blue Shield the right to receive             whom such payments were made.
benefits from the other plan the extent of the
difference between the value of the benefits                Blue Shield may release to or obtain from any
which Blue Shield actually provides and the                 organization or person any information which
value of the benefits that Blue Shield would                Blue Shield considers necessary for the purpose
have been obligated to provide as the secondary             of determining the applicability of and imple-
plan, (2) agrees to cooperate fully with Blue               menting the terms of these provisions or any
Shield in obtaining payment of benefits from                provisions of similar purpose of any other Plan.
the other plan, and (3) allows Blue Shield to ob-           Any person claiming benefits under this Plan
tain confirmation from the other plan that the              shall furnish Blue Shield with such information
benefits which are claimed have not previously              as may be necessary to implement these provi-
been paid.                                                  sions.




                                                      109
SUPPLEMENT TO ORIGINAL MEDICARE PLAN
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                                      110
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 who are not Plan providers will be paid
based on the lesser of the provider’s billed               Domiciliary Care - care provided in a hospital
charges or a reasonable and customary amount,              or other licensed facility because care in the pa-
as determined by Blue Shield).                             tient’s home is not available or is unsuitable.

Benefits (Covered Services) - those services               Dues - the monthly prepayment that is made to
which a Member is entitled to receive pursuant             the Plan on behalf of each Member by the con-
to the terms of the Group Health Service                   tractholder.
Agreement.
                                                           Durable Medical Equipment - equipment de-
Calendar Year - a period beginning at 12:01                signed for repeated use which is medically nec-
a.m. on January 1 and ending at 12:01 a.m. Janu-           essary to treat an illness or injury, to improve
ary 1 of the following year.                               the functioning of a malformed body member,
                                                           or to prevent further deterioration of the pa-
Close Relative - the spouse, domestic partner,             tient’s medical condition. Durable medical
child, brother, sister or parent of a Member.              equipment includes wheelchairs, hospital beds,
                                                           respirators, and other items that the Plan deter-
Copayment - the dollar amount which a Mem-                 mines are durable medical equipment.
ber is required to pay for certain benefits.
                                                           Emergency Services - services for an unex-
Cosmetic Surgery - surgery that is performed               pected medical condition, including a psychiatric
to alter or reshape normal structures of the body          emergency medical condition, manifesting itself
to improve appearance.                                     by acute symptoms of sufficient severity (includ-
                                                           ing severe pain) such that a layperson who pos-
Covered Services (Benefits) - those services               sesses an average knowledge of health and
which a Member is entitled to receive pursuant             medicine could reasonably assume that the ab-
to the terms of the Group Health Service                   sence of immediate medical attention could be
Agreement.                                                 expected to result in any of the following:

                                                     111
GENERAL INFORMATION FOR ALL MEMBERS
1. placing the Member’s health in serious jeop-            sons and holds a license, currently in effect as a
   ardy;                                                   hospice pursuant to Health and Safety Code
                                                           Section 1747, or a home health agency licensed
2. serious impairment to bodily functions; or,             pursuant to Health and Safety Code Sections
                                                           1726 and 1747.1 which has Medicare certifica-
3. serious dysfunction of any bodily organ or              tion.
   part.
                                                           Hospital - either 1., 2. or 3. below:
Employer (Contractholder) - any person,
firm, proprietary or non-profit corporation,               1. a licensed and accredited health facility
partnership, public agency or association that                which is primarily engaged in providing, for
has at least two employees and that is actively               compensation from patients, medical, diag-
engaged in business or service, in which a bona               nostic and surgical facilities for the care and
fide employer-employee relationship exists, in                treatment of sick and injured Members on
which the majority of employees were employed                 an inpatient basis, and which provides such
within this state, and which was not formed                   facilities under the supervision of a staff of
primarily for purposes of buying health care                  physicians and 24 hour a day nursing service
coverage or insurance.                                        by registered nurses. A facility which is prin-
                                                              cipally a rest home, nursing home or home
Experimental or Investigational in Nature -                   for the aged is not included; or,
any treatment, therapy, procedure, drug or drug
usage, facility or facility usage, equipment or            2. a psychiatric hospital licensed as a health fa-
equipment usage, device or device usage, or                   cility accredited by the Joint Commission on
supplies which are not recognized in accordance               Accreditation of Health Care Organizations;
with generally accepted professional medical                  or,
standards as being safe and effective for use in
the treatment of the illness, injury, or condition         3. a “psychiatric health facility” as defined in
at issue. Services which require approval by the              Section 1250.2 of the Health & Safety Code.
federal government or any agency thereof, or by
any State government agency, prior to use and              Independent Practice Association (IPA) - a
where such approval has not been granted at the            group of physicians with individual offices who
time the services or supplies were rendered,               form an organization in order to contract, man-
shall be considered experimental or investiga-             age and share financial responsibilities for pro-
tional in nature. Services or supplies which               viding benefits to Members. For mental health
themselves are not approved or recognized in               and substance abuse services, this definition in-
accordance with accepted professional medical              cludes the MHSA.
standards, but nevertheless are authorized by
law or by a government agency for use in test-             Infertility - either (1) the presence of a demon-
ing, trials, or other studies on human patients,           strated bodily malfunction recognized by a li-
shall be considered experimental or investiga-             censed physician as a cause of infertility or
tional in nature.                                          (2) because of a demonstrated bodily malfunc-
                                                           tion, the inability to conceive a pregnancy or to
Family - the subscriber and all enrolled de-               carry a pregnancy to a live birth after a year or
pendents.                                                  more of regular sexual relations without contra-
                                                           ception, or (3) because of the inability to con-
Group Health Service Agreement (Agree-                     ceive a pregnancy after 6 cycles of artificial
ment) - the Agreement issued by the Plan to the            insemination. These initial 6 cycles are not a
contractholder that establishes the services               benefit of this Plan.
Members are entitled to from the Plan.
                                                           Inpatient - an individual who has been admit-
Hospice or Hospice Agency - an entity which                ted to a hospital as a registered bed patient and
provides hospice services to terminally ill per-

                                                     112
GENERAL INFORMATION FOR ALL MEMBERS
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,

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 22772, 22760 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 Services - see Psychiatric Care.
       which can be provided safely and effec-
                                                           Mental Health Services Administrator
       tively to the patient.
                                                           (MHSA) - Blue Shield of California has con-
3. If there are two or more medically necessary            tracted with the Plan’s Mental Health Services
   services that may be provided for the illness,          Administrator (MHSA). The MHSA is a special-
   injury or medical condition, Blue Shield will           ized health care service plan licensed by the
   provide benefits based on the most cost-                California Department of Managed Health Care,
   effective service.                                      and will underwrite and deliver Blue Shield’s
                                                           mental health and substance abuse services
4. Hospital inpatient services which are medi-             through a unique network of MHSA Participat-
   cally necessary include only those services             ing Providers.
   which satisfy the above requirements, re-


                                                     113
GENERAL INFORMATION FOR ALL MEMBERS
MHSA Participating Provider - a provider                     Participating Hospice or Participating Hos-
who has an agreement in effect with the MHSA                 pice Agency - an entity which: 1) provides
for the provision of mental health and substance             hospice services to terminally ill Members and
abuse services.                                              holds a license, currently in effect, as a hospice
                                                             pursuant to Health and Safety Code Section
Mentally Retarded - only those Members, not                  1747, or a home health agency licensed pursuant
psychotic, who are so mentally retarded from in-             to Health and Safety Code Sections 1726 and
fancy or before reaching maturity that they are              1747.1 which has Medicare certification and
incapable of managing themselves and their af-               2) either has contracted with Blue Shield of Cali-
fairs independently, with ordinary prudence, or              fornia or has received prior approval from Blue
of being taught to do so, and who require su-                Shield of California to provide hospice service
pervision, control and care for their own welfare            benefits pursuant to the California Health and
or for the welfare of others or for the welfare of           Safety Code Section 1368.2.
the community.
                                                             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 Handicap - a physical or mental im-
formities or to improve the function of movable              pairment that results in anatomical, physiologi-
body parts.                                                  cal, or psychological abnormalities which are
                                                             demonstrable by medically acceptable clinical or
Out-of-Area Follow-up Care - non-emergent                    laboratory diagnostic techniques and which are
medically necessary out-of-area services to evalu-           expected to last for a continuous period of time
ate the Member’s progress after an initial emer-             not less than 12 months in duration.
gency or urgent service.
                                                             Physical Therapy - treatment provided by a
Outpatient - an individual receiving services                physician or under the direction of a physician
under the direction of a Plan provider, but not              and provided by a registered physical therapist,
as an inpatient.                                             certified occupational therapist or licensed doc-
                                                             tor of podiatric medicine. Treatment utilizes
Outpatient Facility - a licensed facility, not a             physical agents and therapeutic procedures, such
physician’s office, or a hospital that provides              as ultrasound, heat, range of motion testing, and
medical and/or surgical services on an outpa-                massage, to improve a patient’s musculoskeletal,
tient basis.                                                 neuromuscular and respiratory systems.
Partial Hospitalization/Day Treatment                        Physician - an individual licensed and author-
Program - a treatment program that may be                    ized to engage in the practice of medicine or os-
free-standing or hospital-based and provides                 teopathy.
services at least 5 hours per day and at least 4
days per week. Patients may be admitted directly             Plan - the Blue Shield Access+ HMO Health
to this level of care, or transferred from acute             Plan and/or Blue Shield of California.
inpatient care following acute stabilization.

                                                       114
GENERAL INFORMATION FOR ALL MEMBERS
Plan Hospital - a hospital licensed under appli-            Reconstructive Surgery - surgery to correct or
cable state law contracting specifically with Blue          repair abnormal structures of the body caused
Shield to provide benefits to Members under                 by congenital defects, developmental abnormali-
the Plan.                                                   ties, trauma, infection, tumors or disease to do
                                                            either of the following: (1) to improve function,
Plan Non-Physician Health Care Practitio-                   or (2) to create a normal appearance to the ex-
ner - a health care professional who is not a               tent possible.
physician and has an agreement with one of the
contracted IPAs, medical groups, Plan hospitals             Rehabilitation - inpatient or outpatient care
or Blue Shield to provide covered services to               furnished primarily to restore an individual’s
Members when referred by a Personal Physi-                  ability to function as normally as possible after a
cian. For all mental health and substance abuse             disabling illness or injury. Rehabilitation services
services, this definition includes MHSA Partici-            may consist of physical therapy, occupational
pating Providers.                                           therapy, and/or respiratory therapy and are pro-
                                                            vided with the expectation that the patient has
Plan Provider - a provider who has an agree-                restorative potential. Benefits for speech therapy
ment with Blue Shield to provide Plan benefits              are described in the section on Speech Therapy.
to Members and a MHSA Participating Pro-                    Rehabilitation services will be provided for as
vider.                                                      long as continued treatment is medically neces-
                                                            sary pursuant to the treatment plan.
Plan Service Area - the designated geographical
area, approved by the CalPERS Board of Ad-                  Respiratory Therapy - treatment, under the di-
ministration, within which a Member must live               rection of a physician and provided by a certi-
or work to be eligible for enrollment in this               fied respiratory therapist, to preserve or improve
Plan.                                                       a patient’s pulmonary function.

Plan Specialist - a physician other than a Per-             Serious Emotional Disturbances of a Child -
sonal Physician, psychologist, licensed clinical            refers to individuals who are minors under the
social worker, or licensed marriage and family              age of 18 years who:
therapist who has an agreement with Blue Shield
to provide services to Members either according             1. have one or more mental disorders in the
to an authorized referral by a Personal Physi-                 most recent edition of the Diagnostic and
cian, or according to the Access+ Specialist                   Statistical Manual of Mental Disorders
program, or for OB/GYN physician services.                     (other than a primary substance use disorder
For mental health and substance abuse services,                or developmental disorder), that results in
this definition includes MHSA Participating                    behavior inappropriate for the child’s age
Providers.                                                     according to expected developmental
                                                               norms, and
Prosthesis - an artificial part, appliance or de-
vice used to replace a missing part of the body.            2. meet the criteria in paragraph (2) of subdivi-
                                                               sion (a) of Section 5600.3 of the Welfare
Psychiatric Care (Mental Health Services) -                    and Institutions Code. This section states
psychoanalysis, psychotherapy, counseling,                     that members of this population shall meet
medical management or other services provided                  one or more of the following criteria:
by a psychiatrist, psychologist, licensed clinical
social worker, or licensed marriage and family                  a. As a result of the mental disorder the
therapist, for diagnosis or treatment of mental                    child has substantial impairment in at
or emotional disorder, or the mental or emo-                       least two of the following areas: self-
tional problems associated with illness, injury, or                care, school functioning, family relation-
any other condition.                                               ships, or ability to function in the com-
                                                                   munity; and either of the following has


                                                      115
GENERAL INFORMATION FOR ALL MEMBERS
       occurred: the child is at risk of removal           prove or retrain a patient’s vocal skills which
       from home or has already been removed               have been impaired by diagnosed illness or in-
       from the home or the mental disorder                jury.
       and impairments have been present for
       more than 6 months or are likely to con-            Subacute Care - skilled nursing or skilled reha-
       tinue for more than 1 year without                  bilitation provided in a hospital or skilled nurs-
       treatment;                                          ing facility to patients who require skilled care
                                                           such as nursing services, physical, occupational
    b. The child displays one of the following:            or speech therapy, a coordinated program of
       psychotic features, risk of suicide or risk         multiple therapies or who have medical needs
       of violence due to a mental disorder.               that require daily Registered Nurse monitoring.
                                                           A facility which is primarily a rest home, conva-
Services - includes medically necessary health             lescent facility or home for the aged is not in-
care services and medically necessary supplies             cluded.
furnished incident to those services.
                                                           Supplement to Original Medicare Plan - re-
Severe Mental Illnesses - conditions with the              fers to the supplement of Medicare services by a
following diagnoses: schizophrenia, schizo af-             Health Maintenance Organization (HMO).
fective disorder, bipolar disorder (manic depres-          Medicare HMO coordinated care plans cover
sive illness), major depressive disorders, panic           Medicare deductibles and coinsurance charges
disorder, obsessive-compulsive disorder, perva-            when services are preauthorized or obtained
sive developmental disorder or autism, anorexia            from HMO contracting providers. Members are
nervosa, bulimia nervosa.                                  not restricted to the HMO to receive covered
                                                           Medicare services. However, if services are not
Skilled Nursing Facility - a facility with a valid
                                                           received through the Blue Shield Access+
license issued by the California Department of
                                                           HMO, the services and charges will not be cov-
Health Services as a “skilled nursing facility” or
                                                           ered by the HMO.
any similar institution licensed under the laws of
any other state, territory, or foreign country.            Total Disability -
Special Food Products - a food product which               1. In the case of an employee or Member oth-
is both of the following:                                     erwise eligible for coverage as an employee,
                                                              a disability which prevents the individual
1. Prescribed by a physician or nurse practitio-
                                                              from working with reasonable continuity in
   ner for the treatment of phenylketonuria
                                                              the individual’s customary employment or in
   (PKU) and is consistent with the recom-
                                                              any other employment in which the individ-
   mendations and best practices of qualified
                                                              ual reasonably might be expected to engage,
   health professionals with expertise germane
                                                              in view of the individual’s station in life and
   to, and experience in the treatment and care
                                                              physical and mental capacity.
   of, PKU. It does not include a food that is
   naturally low in protein, but may include a             2. In the case of a dependent, a disability
   food product that is specially formulated to               which prevents the individual from engaging
   have less than one gram of protein per serv-               with normal or reasonable continuity in the
   ing;                                                       individual’s customary activities or in those
                                                              in which the individual otherwise reasonably
2. Used in place of normal food products,
                                                              might be expected to engage, in view of the
   such as grocery store foods, used by the
                                                              individual’s station in life.
   general population.
                                                           Urgent Services - those covered services ren-
Speech Therapy - treatment under the direc-
                                                           dered outside of the Personal Physician service
tion of a physician and provided by a licensed
                                                           area (other than emergency services) which are
speech pathologist or speech therapist, to im-

                                                     116
GENERAL INFORMATION FOR ALL MEMBERS
medically necessary to prevent serious deteriora-         10. Receive preventive health services;
tion of a Member's health resulting from un-
foreseen illness, injury or complications of an           11. Know and understand your medical condi-
existing medical condition, for which treatment               tion, treatment plan, expected outcome and
cannot reasonably be delayed until the Member                 the effects these have on your daily living;
returns to the Personal Physician service area.
                                                          12. Have confidential health records, except
Members Rights and Responsibilities                           when disclosure is required by law or per-
You, as a Blue Shield Access+ HMO Plan                        mitted in writing by you. With adequate no-
Member, have the right to:                                    tice, you have the right to review your
                                                              medical record with your Personal Physi-
1. Receive considerate and courteous care,                    cian;
   with respect for your right to personal pri-
   vacy and dignity;                                      13. Communicate with and receive information
                                                              from Member Services in a language you
2. Receive information about all health ser-                  can understand;
   vices available to you, including a clear ex-
   planation of how to obtain them;                       14. Know about any transfer to another hospi-
                                                              tal, including information as to why the
3. Receive information about your rights and                  transfer is necessary and any alternatives
   responsibilities;                                          available;

4. Receive information about your Access+                 15. Obtain a referral from your Personal Physi-
   HMO Health Plan, the services we offer                     cian for a second opinion;
   you, the physicians and other practitioners
   available to care for you;                             16. Be fully informed about the Blue Shield
                                                              grievances procedure and understand how
5. Select a Personal Physician and expect his/                to use it without fear of interruption of
   her team of health workers to provide or ar-               health care;
   range for all the care that you need;
                                                          17. Voice complaints about the Access+ HMO
6. Have reasonable access to appropriate                      Health Plan or the care provided to you;
   medical services;
                                                          18. Participate in establishing public policy of
7. Participate actively with your physician in                the Blue Shield Access+ HMO, as outlined
   decisions regarding your medical care. To                  in your Evidence of Coverage and Disclo-
   the extent permitted by law, you also have                 sure Form or Health Service Agreement.
   the right to refuse treatment;
                                                          You, as a Blue Shield Access+ HMO Plan
8. A candid discussion of appropriate or medi-            Member, have the responsibility to:
   cally necessary treatment options for your
   condition, regardless of cost or benefit cov-          1. Carefully read all Blue Shield Access+
   erage;                                                    HMO materials immediately after you are
                                                             enrolled so you understand how to use your
9. Receive from your physician an understand-                benefits and how to minimize your out of
   ing of your medical condition and any pro-                pocket costs. Ask questions when necessary.
   posed appropriate or medically necessary                  You have the responsibility to follow the
   treatment alternatives, including available               provisions of your Blue Shield Access+
   success/outcomes information, regardless                  HMO membership as explained in the Evi-
   of cost or benefit coverage, so you can make              dence of Coverage and Disclosure Form or
   an informed decision before you receive                   Health Service Agreement;
   treatment;

                                                    117
GENERAL INFORMATION FOR ALL MEMBERS
2. Maintain your good health and prevent ill-                 structions agreed to by you and the MHSA
   ness by making positive health choices and                 and obtain prior authorization for all non-
   seeking appropriate care when it is needed;                emergency mental health and substance
                                                              abuse services.
3. Provide, to the extent possible, information
   that your physician, and/or the Plan need to           Public Policy Participation Procedure
   provide appropriate care for you;                      This procedure enables you to participate in es-
                                                          tablishing public policy for Blue Shield of Cali-
4. Follow the treatment plans and instructions            fornia. It is not to be used as a substitute for the
   you and your physician have agreed to and              grievance procedure, complaints, inquiries or
   consider the potential consequences if you             requests for information.
   refuse to comply with treatment plans or
   recommendations;                                       Public policy means acts performed by a plan or
                                                          its employees and staff to assure the comfort,
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
                                                                  Blue Shield of California
   Shield Access+ HMO Plan;
                                                                  Director, Consumer Affairs
9. Help Blue Shield to maintain accurate and                      50 Beale Street
   current medical records by providing timely                    San Francisco, CA 94105
   information regarding changes in address,                      Phone Number: 415-229-5104
   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
11. Select a Personal Physician for your new-                 the above address, who will acknowl-
    born before birth, when possible, and notify              edge receipt of your letter;
    Blue Shield as soon as you have made this               • Your name, address, phone number,
    selection;                                                subscriber number and group number
                                                              should be included with each communi-
12. Treat all Plan personnel respectfully and                 cation;
    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

                                                    118
GENERAL INFORMATION FOR ALL MEMBERS
   meetings will reflect decisions on public               Access to Information
   policy issues that were considered. If you              Blue Shield of California may need information
   have initiated a policy issue, appropriate              from medical providers, from other carriers or
   extracts of the minutes will be furnished               other entities, or from you, in order to adminis-
   to you within 10 business days after the                ter benefits and eligibility provisions of this
   minutes have been approved.                             Agreement. You agree that any provider or en-
                                                           tity can disclose to Blue Shield that information
Confidentiality of Medical Records and                     that is reasonably needed by Blue Shield. You
Personal Health Information                                agree to assist Blue Shield in obtaining this in-
Blue Shield of California protects the confiden-           formation, if needed, (including signing any nec-
tiality/privacy of your personal health informa-           essary authorizations) and to cooperate by
tion. Personal and health information includes             providing Blue Shield with information in your
both medical information and individually iden-            possession. Failure to assist Blue Shield in ob-
tifiable information, such as your name, address,          taining necessary information or refusal to pro-
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                              Benefits of this Plan are not assignable.
YOU UPON REQUEST. Blue Shield’s policies
and procedures regarding our confidential-                 Facilities
ity/privacy practices are contained in the “No-            The Plan has established a network of physi-
tice of Privacy Practices,” which you may obtain           cians, hospitals, participating hospice agencies
either by calling the Member Services Depart-              and non-physician health care practitioners in
ment at the number listed on the back cover of             your service area.
this booklet, or by accessing Blue Shield of Cali-
fornia’s      internet     site    located     at          The Personal Physician(s) you and your depend-
http://www.blueshieldca.com and printing a                 ents select will provide telephone access 24
copy.                                                      hours a day, 7 days a week so that you can ob-
                                                           tain assistance and prior approval of medically
If you are concerned that Blue Shield may have             necessary care. The hospitals in the Plan net-
violated your confidentiality/privacy rights, or           work provide access to 24-hour emergency ser-
you disagree with a decision we made about ac-             vices. The list of the hospitals, physicians and
cess to your personal and health information,              participating hospice agencies in your service
you may contact us at:                                     area indicates the location and phone numbers
                                                           of these providers. Contact Member Services at
Correspondence Address:                                    the number listed on the back cover of this
Blue Shield of California Privacy Official                 booklet for information on Plan non-physician
P.O. Box 272540                                            health care practitioners in your Personal Physi-
Chico, CA 95927-2540                                       cian Service Area.
Toll-Free Telephone:                                       For urgent services when you are within the
1-888-266-8080                                             United States, you simply call toll-free 1-800-
                                                           810-BLUE (2583) 24 hours a day, 7 days a week.
Email Address:                                             For urgent services when you are outside the
blueshieldca_privacy@blueshieldca.com                      United States, you can call collect 1-804-673-

                                                     119
GENERAL INFORMATION FOR ALL MEMBERS
1177 24 hours a day. We will identify the Blue-            Access+ Satisfaction
Card Program participating provider closest to             You may provide Blue Shield with feedback re-
you. Urgent services when you are outside the              garding the service you receive from Plan physi-
United States are available through the BlueCard           cians. Return the prepaid postcard available
Worldwide Network. For urgent services when                from Member Services to Blue Shield. If you are
you are within California, but outside of your             dissatisfied with the service provided during an
Personal Physician Service Area, you should                office visit with a Plan physician, you may re-
contact your Personal Physician or Blue Shield             quest a refund of your office visit copayment, as
Member Services in accordance with the How                 shown in the Summary of Benefits under Physi-
to Use the Plan section. For urgent services               cian Services.
when you are within your Personal Physician
Service Area, contact your Personal Physician to           Web Site
obtain urgent services which must be provided              Blue Shield’s Web site is located at
or authorized by your Personal Physician just              http://www.blueshieldca.com. Members with
like all other non-emergency services of the               Internet access and a Web browser may view
Plan.                                                      and download health care information.
Independent Contractors                                    Utilization Review Process
Plan providers are neither agents nor employees            State law requires that health plans disclose to
of the Plan but are independent contractors.               Members and health plan providers the process
Blue Shield of California conducts a process of            used to authorize or deny health care services
credentialling and certification of all physicians         under the plan.
who participate in the Access+ HMO network.
However, in no instance shall the Plan be liable           Blue Shield has completed documentation of
for the negligence, wrongful acts or omissions             this process ("Utilization Review"), as required
of any person receiving or providing services,             under Section 1363.5 of the California Health &
including any physician, hospital, or other pro-           Safety Code.
vider or their employees.
                                                           To request a copy of the document describing
                                                           this Utilization Review, call the Member Ser-
                                                           vices Department at 1-800-334-5847.




                                                     120
GENERAL INFORMATION FOR ALL MEMBERS
Preventive Health Guidelines
For children ages 0-2 years
Immunizations
DTaP (diphtheria, tetanus, acellular pertussis)   Four doses: 2, 4, 6, 15-18 months
Flu                                               6-59 months recommended to receive vaccine annually
Hepatitis A                                       12-23 months (second dose at least 6 months after
                                                  first)
Hepatitis B                                       Three doses: 0 (birth), 1-2, 4-6 months
Hib (Haemophilus influenzae type b)               Four doses: 2, 4, 6, 12-15 months
IPV (inactivated poliovirus vaccine)              Three doses: 2, 4, 6-18 months
MMR (measles, mumps, rubella)                     First dose at 12-15 months, second dose at 4-6 years
Pneumococcal                                      Four doses: 2, 4, 6, 12-15 months
Rotavirus                                         Three doses: 2, 4, 6 months
Varicella (chickenpox)                            First dose at 12-15 months, second dose at 4-6 years
Screenings
Length, weight, blood tests and antibiotic eye    In first week of life
drops
Height and weight checks, vision and hearing      Periodically
tests
For children ages 3-11 years
Immunizations
DTaP (diphtheria, tetanus, acellular pertussis)   4-6 years (fifth in a series of 5)
Flu                                               Annually, for children 6-59 months; 6 years and older
                                                  if risk factors are present
Hepatitis B                                       For individuals with risk factors (at current visit, then
                                                  at 1 and 6 months)
IPV (inactivated poliovirus vaccine)              4-6 years (fourth in a series of 4)
MMR (measles, mumps, rubella)                     Second dose at 4-6 years (second in a series of 2)
Pneumococcal                                      For children with risk factors (at 24-59 months)
Tdap booster (tetanus, diphtheria, pertussis)     At pre-adolescent visit (11-12 years)
Meningococcal                                     At pre-adolescent visit (11-12 years)
Varicella (chickenpox)                            Second dose at 4-6 years (second in a series of 2)
HPV (human papillomavirus)                        A three-shot series at pre-adolescent visit for females
                                                  ages 11-12 years. May also be given to females ages
                                                  9-26
Screenings
Diabetes                                          Ages 10-45, screen every 2 years if overweight
Height and weight checks, vision and hearing      Periodically
tests




                                                   121
GENERAL INFORMATION FOR ALL MEMBERS

For children ages 12-19 years
Immunizations
Flu                                             Annually, for individuals with risk factors
Hepatitis B                                     For individuals with risk factors (at current visit, then
                                                at 1 and 6 months)
Meningococcal                                   At pre-adolescent visit (11-12 years). If no prior shot, a
                                                dose at high school entry or for college-bound stu-
                                                dents is recommended
MMR (measles, mumps, rubella)                   At pre-adolescent visit (11-12 years) if missing second
                                                dose
Pneumococcal                                    For children with risk factors
Rubella (German measles)                        Recommended for all women of childbearing age, if
                                                susceptible
Tdap booster (tetanus, diphtheria, pertussis)   At pre-adolescent visit (11-12 years); at 19 years, once
                                                every 10 years or sooner if risk factors are present
Varicella (chickenpox)                          At pre-adolescent visit (11-12 years) if missing second
                                                dose
HPV (human papillomavirus)                      A three-shot series at pre-adolescent visit for females
                                                ages 11-12 years. May also be given to females ages
                                                9-26
Screenings
Blood pressure                                  At least every 2 years, beginning at age 18
Diabetes                                        Ages 10-45, screen every 2 years if overweight
Cervical cancer                                 Pap test and HPV test: at least every 3 years beginning
                                                at age 21 or within 3 years of onset of sexual activity
Chlamydia                                       Recommended for all sexually active women under age
                                                26 and for women at high risk for infection
Syphilis                                        Routine screening for pregnant women and individuals
                                                at high risk for infection
Rubella susceptibility                          Recommended for all women of childbearing age
Height and weight checks, vision and hearing    Periodically
tests
HIV screening                                   For all adolescents at risk for HIV infection




                                                 122
GENERAL INFORMATION FOR ALL MEMBERS

For men ages 20-49 years
Immunizations
Flu                                             Annually, for all adults with risk factors
Hepatitis A                                     For individuals with risk factors
Hepatitis B                                     For individuals with risk factors (at current visit, then
                                                at 1 and 6 months)
Meningococcal                                   College-bound students or persons at risk should dis-
                                                cuss the benefits of vaccination with their doctor
MMR (measles, mumps, rubella)                   Once, without proof of immunity or if no previous
                                                second dose
Pneumococcal                                    For individuals with risk factors
Tdap booster (tetanus, diphtheria, pertussis)   Once every 10 years or sooner if risk factors are pre-
                                                sent
Varicella (chickenpox)                          All adults without evidence of immunity
Screenings
Blood pressure                                  At least every 2 years
Cholesterol                                     Periodically, starting at age 35 (age 20 if risk factors are
                                                present)
Diabetes                                        To age 45, every 2 years if overweight; over age 45,
                                                every 3 years and more often if overweight; for all
                                                adults with high blood pressure or cholesterol
Syphilis                                        Routine screening for individuals at high risk for infec-
                                                tion
Height and weight checks, vision and hearing    Periodically
tests
HIV screening                                   For all adults at risk for HIV infection




                                                 123
GENERAL INFORMATION FOR ALL MEMBERS

For women ages 20-49 years
Immunizations
Flu                                             Annually, for all adults with risk factors
Hepatitis A                                     For individuals with risk factors
Hepatitis B                                     For individuals with risk factors
HPV (human papillomavirus)                      For all women 26 years and younger
Meningococcal                                   College-bound students or persons at risk should dis-
                                                cuss the benefits of vaccination with their doctor
MMR (measles, mumps, rubella)                   Once, without proof of immunity or if no previous
                                                second dose
Pneumococcal                                    For individuals with risk factors
Rubella (German measles)                        Recommended for all women of childbearing age, if
                                                susceptible
Tdap booster (tetanus, diphtheria, pertussis)   Once every 10 years or sooner if risk factors are pre-
                                                sent
Varicella (chickenpox)                          All adults without evidence of immunity
Screenings
Blood pressure                                  At least every 2 years
Cholesterol                                     Periodically, starting at age 35 (age 20 if risk factors are
                                                present)
Diabetes                                        To age 45, every 2 years if overweight; over age 45,
                                                every 3 years and more often if overweight; for all
                                                adults with high blood pressure or cholesterol
Breast cancer                                   Beginning at age 40, mammogram every 1-2 years with
                                                an annual clinical breast exam
Cervical cancer                                 Pap test and HPV test: At least every 3 years beginning
                                                at age 21 or within 3 years of onset of sexual activity
Chlamydia                                       Recommended for all sexually active women under age
                                                26 and for women at high risk for infection; periodi-
                                                cally for all other women
Syphilis                                        Routine screening for individuals at high risk for infec-
                                                tion
Rubella susceptibility                          Recommended for all women of childbearing age
Osteoporosis                                    Evaluation of risk factors for women (especially post-
                                                menopausal); women at high risk may need a screening
                                                test
Height and weight checks, vision and hearing    Periodically
tests
HIV screening                                   For all adults at risk for HIV infection




                                                 124
GENERAL INFORMATION FOR ALL MEMBERS

For men and women ages 50 and older
Immunizations
Flu                                             Annually, for ages 50 and older
Hepatitis A                                     For individuals with risk factors
Hepatitis B                                     For individuals with risk factors
Meningococcal                                   Individuals with risk factors should discuss vaccination
                                                with their doctor
Pneumococcal vaccine                            For individuals with risk factors. At 65 and older: once
MMR (measles, mumps, rubella)                   Once, without proof of immunity or if no previous
                                                second dose
Tdap booster (tetanus, diphtheria, pertussis)   Once every 10 years or sooner if risk factors are pre-
                                                sent
Varicella (chickenpox)                          All adults without evidence of immunity
Zoster (shingles)                               All adults 60 and older
Screenings
Blood pressure                                  At least every 2 years
Cholesterol                                     Periodically
Colorectal cancer                               Fecal occult blood test annually and flexible sigmoido-
                                                scopy every 5 years, or double-contrast barium enema
                                                every 5-10 years, or colonoscopy every 10 years
Diabetes                                        Every 3 years and more often if overweight, high
                                                blood pressure or cholesterol
Breast cancer                                   For women ages 40-69, mammogram every 1-2 years
                                                with an annual clinical breast exam
Cervical cancer                                 At least every 3 years. After age 65, Pap tests can be
                                                discontinued if previous tests have been normal
Chlamydia                                       Periodically for women
Syphilis                                        Routine screening for pregnant women and individuals
                                                at high risk for infection
Height and weight checks, vision and hearing    Periodically
tests
Osteoporosis                                    Evaluation of risk factors for women (especially post-
                                                menopausal); women at high risk may need a screening
                                                test; 65 and older: routine screening
AAA (abdominal aortic aneurysm)                 For men ages 65-75 who have ever smoked, one-time
                                                screening for AAA by ultrasonography
HIV screening                                   For all adults at risk for HIV infection




                                                 125
GENERAL INFORMATION FOR ALL MEMBERS
Service Area
The service areas and providers of this Plan are identified in the Blue Shield HMO Physician and Hos-
pital Directories. Contact the Plan for up-to-date confirmation. You must live or work in the ser-
vice 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 depend-
ents 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.


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

                                                    126
GENERAL INFORMATION FOR ALL MEMBERS
 Morongo Valley              Bonita                     Mount Laguna       San Francisco County1
 Mount Baldy                 Bonsall                    National City        (Entire County Served)
 Mountain Pass               Borrego Springs            North Island NAS   San Joaquin County1
 Newberry Springs            Bostonia                   Ocean Beach          (Entire County Served)
 Nipton                      Boulevard                  Oceanside          San Luis Obispo
 Ontario                     Camp Pendleton             Otay Mesa
                                                                           County4
 Oro Grande                  Campo                      Pacific Beach
                                                                             (Entire County Served)
 Patton                      Cardiff by the Sea         Pala
 Phelan                      Carlsbad                   Palomar Mountain   San Mateo County1
 Pinon Hills                 Chula Vista                Pauma Valley         (Entire County Served)
 Pioneertown                 Coronado                   Pine Valley        Santa Barbara County4
 Rancho Cucamonga            Del Mar                    Point Loma           (Entire County Served)
 Red Mountain                Descanso                   Potrero            Santa Clara County1
 Redlands                    Dulzura                    Poway                (Entire County Served)
 Rialto                      El Cajon                   Ramona             Santa Cruz County1
 Rimforest                   Encinitas                  Ranchita             (Entire County Served)
 Running Springs             Escondido                  Rancho Bernardo
 San Bernardino              Fallbrook                  Rancho Santa Fe    Solano County1
 Skyforest                   Grossmont                  San Diego            (Entire County Served)
 Sugarloaf                   Guatay                     San Luis Rey       Sonoma County1
 Trona                       Imperial Beach             San Marcos           (Entire County Served)
 Twentynine Palms            Jamul                      San Ysidro         Stanislaus County2
 Twin Peaks                  Julian                     Santa Ysabel         (Entire County Served)
 Upland                      La Jolla                   Santee             Tulare County4
 Victorville                 La Mesa                    Solana Beach         (Entire County Served)
 Wrightwood                  Lakeside                   Spring Valley
                                                                           Ventura County3
 Yermo                       Lemon Grove                Tecate
                                                                             (Entire County Served)
 Yucaipa                     Leucadia                   Valley Center
 Yucca Valley                Lincoln Acres              Vista              Yolo County1
San Diego County4            Mira Mesa                  Warner Springs       (Entire County Served)
 Alpine                      Miramar NAS


Pricing Regions for Contracting Agency Employees and Annuitants
(Not Applicable to Supplement to Original Medicare Plan Enrollees)
1   San Francisco Bay Area/Sacramento Counties
2   Other Northern California Counties
3   Los Angeles/Ventura/San Bernardino Counties
4   Other Southern California Counties




                                                  127
Notes




 128
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
                                                                           Colusa
                                                                           Glenn
                                                                           Humboldt
                                                                           Mendocino
                                                                           Nevada
                                                                           Sierra
                                                                                            Gr­eater­ Sacr­amento
                                                                                            El Dorado (HMO)
                                                                                            Placer
                                                                                            Sacramento
                                                                                            Yolo
                                                                                                              Centr­al Valley
                      Nor­th Bay                                                                              Fresno
                      Marin                                                                                   Kern
                      Solano                                                                                  Kings
                      Sonoma                                                                                  Madera
                                                                                                              Mariposa
                          San Fr­ancisco                                                                      Merced
                                                                                                              San Joaquin
                              East Bay                                                                        Stanislaus
                              Alameda                                                                         Tulare
                              Contra Costa
                                    Peninsula
                                    San Mateo

                                        South Bay
                                        Santa Clara
                                        Santa Cruz



                                                 San Luis Obispo

                                                                    Santa                                       San Ber­nar­dino
                                                                    Bar­bar­a
                                                                                            Los
                                                                                            Angeles

                                                                        Ventur­a
                                                                                                                     River­side
                                                                                           Or­ange

                                                                                                             San Diego          Imper­ial




                                                                                                                                            An Independent Member of the Blue Shield Association
                   Refer to Section 3, pages 126 – 127 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


A10778-11 (1/08)

				
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