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Small Sales Contract Template - Excel

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Small Sales Contract Template - Excel Powered By Docstoc
					Instructions for Customizable Plan Comparison Template

1. Type in the Group Name, Effective Date, Producer Name and Number in the fields highlighted in YELLOW.
Once you type this information in, it will automatically populate in the page header

2. To select the plans of your choice, click on the BLUE plan name headers, and use the drop down menu to choose the
relevant plans.

3. This template consists of 31 plans fitted across seven (7) pages.

       Pages 1, 3, 4 have space to display four (4) plans each.

       Pages 2, 5 have space to display five (5) plans each.

       Page 6 has space to display six (6) plans each.

       Page 7 has space to display three (3) plans.

4. To print all the plans, go to FILE>PRINT> and make sure „All‟ is selected in the „Print Range‟ field.

5. If you need to print fewer than the entire selection, then click on the BLUE plan name headers, and choose the relevant
plans.

For the remaining columns, click on the blue headers and choose the “Click the Drop-Down Arrow to choose the Blue Shield
of California” option

The template will then display your selected plans, and the other columns will show "-" in all the fields.

Then go to FILE>PRINT> and in the „Print Range‟ field, choose the page numbers you want printed (e.g. Pages From: 1 To: 3)

6. DO NOT hide the columns

7. DO NOT make any text edits to the benefits fields or plan names.

8. Please save one copy of this template in its original format on your hard-drive. Whenever you customize the template for a
new group, open this original file and SAVE it AS a NEW file for that particular group. This will prevent formatting errors from
occurring.
8. Please save one copy of this template in its original format on your hard-drive. Whenever you customize the template for a
new group, open this original file and SAVE it AS a NEW file for that particular group. This will prevent formatting errors from
occurring.
                                             Small Group Plan Comparison for XYZ Group with an Effective Date of 7/1/2009
          The table below can help you choose the Blue Shield coverage that's right for you. Please remember, this side-by-side comparison is only a brief overview.                                                                   The table bel
                                                       Questions? Please contact ABC Producer at (999) 999-9999

                                    Access+ HMO® Plan 5                              Access+ HMO® Plan 10                              Access+ HMO® Plan 15                              Access+ HMO® Plan 20

                                            In-network Benefits                               In-network Benefits                               In-network Benefits                              In-network Benefits


Copayment Percentage/Co-
                                                    N/A                                               N/A                                               N/A                                               N/A
      pay Amount

     Lifetime Maximum                              None                                              None                                              None                                              None

  Calendar-Year Medical
        Deductible                                 None                                              None                                              None                                              None
    (Individual/Family)


Calendar-Year Copayment
         Maximum                               $1,500/$3,000                                     $2,000/$4,000                                     $2,000/$4,000                                     $2,500/$5,000
    (Individual/Family)




        Office Visits                             $5/visit                                          $10/visit                                         $15/visit                                         $20/visit




      Preventive Care                           No Charge                                         No Charge                                         No Charge                                         No Charge



  Inpatient Hospitalization
                                                No Charge                                       $100/admission                                    $300/admission                                   $1000/admission
     Services (Facility)




Outpatient Surgery (Hospital)                   No Charge                                         $50/surgery                                      $250/surgery                                      $500/surgery



     Outpatient Surgery
                                                No Charge                                         $30/surgery                                      $150/surgery                                      $300/surgery
           (ASC)

     Emergency Room
   (Not resulting in direct                      $100/visit                                        $100/visit                                        $100/visit                                        $100/visit
         admission)
Calendar-Year Brand-Name
                                                   None                                              None                                              None                                         $150/member
     Drug Deductible

                                             $10 Generic drug                                  $10 Generic drug                                  $15 Generic drug                                  $15 Generic drug




  Retail Drug Copayments              $25 Formulary brand-name drug                     $25 formulary brand-name drug                    $30 Formulary brand-name drug                     $30 Formulary brand-name drug




                                   $45 Non-formulary brand-name drug                 $45 Non-formulary brand-name drug                 $45 Non-formulary brand-name drug                 $45 Non-formulary brand-name drug


  Note 1: This document is only a summary for informational purposes. It is not a contract. Please refer to the Certificate of Insurance/Group Policy or Evidence of Coverage/Plan Contract for the exact terms and conditions of
coverage. Benefits are subject to modification by Blue Shield for subsequently enacted state or federal legislation. Plans 750 Value, 1000 Value, 1500 Value, 2000 Value, Shield Savings 1800/3600, and Shield Savings 2000/4000 are
pending regulatory approval. Note 2: *Plan Underwritten by Blue Shield of California Life & Health Insurance Company. Note 3: **Employees and all enrolled dependents must live or work in the specified service area. The service
                       area for Local Access+ HMO plans includes portions of Los Angeles, Orange, San Diego, San Bernardino, and Riverside Counties as described in the Benefit Summary Guide A16609 .
                                                                      Small Group Plan Comparison for XYZ Group with an Effective Date of 7/1/2009
                                   The table below can help you choose the Blue Shield coverage that's right for you. Please remember, this side-by-side comparison is only a brief overview.                                                                                               The table bel
                                                                                Questions? Please contact ABC Producer at (999) 999-9999
                                    Access+ HMO® Plan 20                                                                                                                                                                                     Local Access+ HMO® Plan
                                                                                    Access+ HMO® Plan 30                                Access+ HMO® Plan 25                                Access+ HMO® Plan 40
                                           Value                                                                                                                                                                                                    20 Value**
                                            In-network Benefits                               In-network Benefits                                 In-network Benefits                                 In-network Benefits                               In-network Benefits


Copayment Percentage/Co-
                                                    N/A                                               N/A                                                 25%                                                 40%                                               N/A
      pay Amount

     Lifetime Maximum                              None                                              None                                                None                                                None                                              None

  Calendar-Year Medical
        Deductible                                 None                                              None                                                None                                                None                                              None
    (Individual/Family)


Calendar-Year Copayment
         Maximum                               $3,000/$6,000                                     $3,500/$7,000                                       $3,500/$7,000                                       $4,000/$8,000                                     $3,000/$6,000
    (Individual/Family)




        Office Visits                             $20/visit                                         $30/visit                                           $25/visit                                           $40/visit                                         $20/visit




      Preventive Care                            No Charge                                        No Charge                                           No Charge                                           No Charge                                          No Charge


                                   $400/day (up to 3 days max per admit)                                                                                                                                                                       $400/day (up to 3 days max per admit)
  Inpatient Hospitalization
                                Copayment is waived if the member is directly       $500/day (up to 3 days max per admit)                       25% of allowed charges                              40% of allowed charges                  Copayment is waived if the member is directly
     Services (Facility)
                                    admitted from the emergency room                                                                                                                                                                            admitted from the emergency room



Outpatient Surgery (Hospital)                   $500/surgery                                     $500/surgery                                   25% of allowed charges                              40% of allowed charges                                  $500/surgery



     Outpatient Surgery
                                                $300/surgery                                     $350/surgery                                   25% of allowed charges                              40% of allowed charges                                  $300/surgery
           (ASC)

     Emergency Room                              $100/visit                                                                                                                                                                                                  $100/visit
   (Not resulting in direct     Copayment is waived if the member is directly                      $150/visit                                          $150/visit                                          $200/visit                       Copayment is waived if the member is directly
         admission)               admitted to the hospital as an inpatient                                                                                                                                                                    admitted to the hospital as an inpatient
Calendar-Year Brand-Name
                                               $150/member                                       $150/member                                         $250/member                                         $250/member                                       $150/member
     Drug Deductible

                                              $15 Generic drug                                 $15 Generic drug                                    $15 Generic drug                                    $15 Generic drug                                   $15 Generic drug




  Retail Drug Copayments              $30 Formulary brand-name drug                    $30 Formulary brand-name drug                       $30 Formulary brand-name drug                       $30 Formulary brand-name drug                      $30 Formulary brand-name drug


                                 Non-formulary drugs are not covered (unless                                                                                                                                                                 Non-formulary drugs are not covered (unless
                                                                                 Non-formulary drugs are not covered (unless         Non-formulary drugs are not covered (unless         Non-formulary drugs are not covered (unless
                                   prior authorization is obtained from Blue                                                                                                                                                                   prior authorization is obtained from Blue
                                                                                prior authorization is obtained from Blue Shield)   prior authorization is obtained from Blue Shield)   prior authorization is obtained from Blue Shield)
                                                     Shield)                                                                                                                                                                                                     Shield)
Note 1: This document is only a summary for informational purposes. It is not a contract. Please refer to the Certificate of Insurance/Group Policy or Evidence of Coverage/Plan Contract for the exact terms and conditions of coverage. Benefits are subject to modification by
  Blue Shield for subsequently enacted state or federal legislation. Plans 750 Value, 1000 Value, 1500 Value, 2000 Value, Shield Savings 1800/3600, and Shield Savings 2000/4000 are pending regulatory approval. Note 2: *Plan Underwritten by Blue Shield of California Life &
  Health Insurance Company. Note 3: **Employees and all enrolled dependents must live or work in the specified service area. The service area for Local Access+ HMO plans includes portions of Los Angeles, Orange, San Diego, San Bernardino, and Riverside Counties as
                                                                                                                    described in the Benefit Summary Guide A16609.
                                              Small Group Plan Comparison for XYZ Group with an Effective Date of 7/1/2009
           The table below can help you choose the Blue Shield coverage that's right for you. Please remember, this side-by-side comparison is only a brief overview.                                                                The table below can help you
                                                        Questions? Please contact ABC Producer at (999) 999-9999
                                  Local Access+ HMO® Plan                            Shield Spectrum PPO Plan,                     Shield Spectrum PPO Plan 250 Shield Spectrum PPO Plan 250
                                            30**                                          Zero Deductible                                     Premier                     Standard
                                                                                               Preferred Providers                              Preferred Providers                               Preferred Providers
                                              In-network Benefits
                                                                                             Non-Preferred Providers                          Non-Preferred Providers                           Non-Preferred Providers

Copayment Percentage/Co-                                                                      Preferred Providers: 10%                        Preferred Providers: 10%                          Preferred Providers: 20%
                                                      N/A
      pay Amount                                                                            Non-Preferred Providers: 30%                    Non-Preferred Providers: 30%                      Non-Preferred Providers: 40%

     Lifetime Maximum                                None                                            $6,000,000                                      $6,000,000                                        $6,000,000

  Calendar-Year Medical
                                                                                             Preferred Providers: $0/$0
        Deductible                                   None                                                                                All Providers Combined: $250/$500                 All Providers Combined: $250/$500
                                                                                        Non-Preferred Providers: $500/$1,000
    (Individual/Family)


Calendar-Year Copayment
                                                                                         Preferred Providers: $2,000/$4,000              Preferred Providers: $2,500/$5,000                Preferred Providers: $3,000/$6,000
         Maximum                                 $3,500/$7,000
                                                                                       Non-Preferred Providers: $5,000/$10,000        Non-Preferred Providers: $10,000/$20,000          Non-Preferred Providers: $10,000/$20,000
    (Individual/Family)




                                                                                            Preferred Providers: $10/visit                  Preferred Providers: $15/visit                    Preferred Providers: $25/visit
        Office Visits                               $30/visit
                                                                                            Non-Preferred Providers: 30%                    Non-Preferred Providers: 30%                      Non-Preferred Providers: 40%




                                                                                           Preferred Providers: $10/visit                  Preferred Providers: $15/visit                    Preferred Providers: $25/visit
      Preventive Care                             No Charge
                                                                                       Non-Preferred Providers: Not Covered            Non-Preferred Providers: Not Covered              Non-Preferred Providers: Not Covered


                                                                                               Preferred Providers: 10%                       Preferred Providers: 10%                          Preferred Providers: 20%
  Inpatient Hospitalization
                                    $500/day (up to 3 days max per admit)           Non-Preferred Providers: 30% up to $600/day+   Non-Preferred Providers: 30% up to $600/day+      Non-Preferred Providers: 40% up to $600/day+
     Services (Facility)
                                                                                           excess charges over $600/day                   excess charges over $600/day                      excess charges over $600/day


                                                                                               Preferred Providers: 10%                       Preferred Providers: 10%                          Preferred Providers: 20%
Outpatient Surgery (Hospital)                    $500/surgery                       Non-Preferred Providers: 30% up to $600/day+   Non-Preferred Providers: 30% up to $600/day+      Non-Preferred Providers: 40% up to $600/day+
                                                                                           excess charges over $600/day                   excess charges over $600/day                      excess charges over $600/day

                                                                                               Preferred Providers: 10%
                                                                                                                                              Preferred Providers: 10%                         Preferred Providers : 10%
     Outpatient Surgery                                                             Non-Preferred Providers: 30% up to $600/day+
                                                 $350/surgery                                                                      Non-Preferred Providers: 30% up to $600/day+      Non-Preferred Providers: 40% up to $600/day+
           (ASC)                                                                           excess charges over $600/day
                                                                                                                                          excess charges over $600/day                      excess charges over $600/day

     Emergency Room
   (Not resulting in direct                        $150/visit                                        $100 + 10%                                      $100 + 10%                                        $100 + 20%
         admission)
Calendar-Year Brand-Name
                                                 $150/member                                            None                                            None                                              None
     Drug Deductible

                                               $15 Generic drug                                  $10 Generic drug                                 $10 Generic drug                                  $10 Generic drug




  Retail Drug Copayments               $30 Formulary brand-name drug                      $25 Formulary brand-name drug                   $25 Formulary brand-name drug                     $30 Formulary brand-name drug



                                 Non-formulary drugs are not covered (unless
                                                                                        $50 Non-formulary brand-name drug               $50 Non-formulary brand-name drug                 $50 Non-formulary brand-name drug
                                prior authorization is obtained from Blue Shield)

   Note 1: This document is only a summary for informational purposes. It is not a contract. Please refer to the Certificate of Insurance/Group Policy or Evidence of Coverage/Plan Contract for the exact terms and conditions of
   coverage. Benefits are subject to modification by Blue Shield for subsequently enacted state or federal legislation. Plans 750 Value, 1000 Value, 1500 Value, 2000 Value and Shield Savings 1800/3600 are pending regulatory
   approval. Note 2: *Plan Underwritten by Blue Shield of California Life & Health Insurance Company. Note 3: **Employees and all enrolled dependents must live or work in the specified service area. The service area for Local
                               Access+ HMO plans includes portions of Los Angeles, Orange, San Diego, San Bernardino, and Riverside Counties as described in the Benefit Summary Guide A16609 .
                                             Small Group Plan Comparison for XYZ Group with an Effective Date of 7/1/2009
          The table below can help you choose the Blue Shield coverage that's right for you. Please remember, this side-by-side comparison is only a brief overview.                                                                    The table be
                                                       Questions? Please contact ABC Producer at (999) 999-9999
                                Shield Spectrum PPO Plan 500 Shield Spectrum PPO Plan 500                                            Shield Spectrum PPO Plan                           Shield Spectrum PPO Plan
                                           Premier                     Standard*                                                               1000                                               3000*
                                           Preferred Providers                               Preferred Providers                               Preferred Providers                                Preferred Providers
                                         Non-Preferred Providers                           Non-Preferred Providers                           Non-Preferred Providers                            Non-Preferred Providers

Copayment Percentage/Co-                  Preferred Providers: 20%                         Preferred Providers: 30%                           Preferred Providers: 25%                          Preferred Providers: 20%
      pay Amount                        Non-Preferred Providers: 40%                     Non-Preferred Providers: 50%                       Non-Preferred Providers: 50%                      Non-Preferred Providers: 50%

     Lifetime Maximum                            $6,000,000                                        $6,000,000                                        $6,000,000                                        $6,000,000

  Calendar-Year Medical
        Deductible                  All Providers Combined: $500/$1,000              All Providers Combined: $500/$1,000               All Providers Combined: $1,000/$2,000             All Providers Combined: $3,000/$6,000
    (Individual/Family)
                                                                                                                                                                                           Preferred Providers: $6,000/12,000
Calendar-Year Copayment                                                                                                                                                                Non-Preferred Providers: Charges for non-
                                     Preferred Providers: $3,500/$7,000               Preferred Providers: $4,000/$8,000                Preferred Providers: $5,000/$10,000
         Maximum                                                                                                                                                                        emergency services received from non-
                                  Non-Preferred Providers: $10,000/$20,000         Non-Preferred Providers: $10,000/$20,000           Non-Preferred Providers: $10,000/$20,000
    (Individual/Family)                                                                                                                                                               preferred providers do not count toward the
                                                                                                                                                                                     calendar-year copayment maximum and are




                                        Preferred Providers: $35/visit                   Preferred Providers: $40/visit                     Preferred Providers: $45/visit                      Preferred Providers: 20%
        Office Visits
                                        Non-Preferred Providers: 40%                     Non-Preferred Providers: 50%                       Non-Preferred Providers: 50%                      Non-Preferred Providers: 50%




                                       Preferred Providers: $35/visit                    Preferred Providers: $40/visit                    Preferred Providers: $45/visit                    Preferred Providers: $45/visit
      Preventive Care
                                   Non-Preferred Providers: Not Covered              Non-Preferred Providers: Not Covered              Non-Preferred Providers: Not Covered              Non-Preferred Providers: Not Covered


                                   Preferred Providers: $250/admit + 20%            Preferred Providers: $500/admit + 30%             Preferred Providers: $1,000/year + 25%              Preferred Providers: $500/year + 20%
  Inpatient Hospitalization
                                Non-Preferred Providers: 40% up to $600/day+     Non-Preferred Providers: 50% up to $600/day+      Non-Preferred Providers: 50% up to $600/day+     Non-Preferred Providers: 50% of up to $600/day +
     Services (Facility)
                                       excess charges over $600/day                     excess charges over $600/day                      excess charges over $600/day                       excess charges over $600/day


                                  Preferred Providers: $150/surgery + 20%          Preferred Providers: $250/surgery + 30%           Preferred Providers: $500/surgery + 25%            Preferred Providers: $250/surgery + 20%
Outpatient Surgery (Hospital)   Non-Preferred Providers: 40% up to $600/day+     Non-Preferred Providers: 50% up to $600/day+      Non-Preferred Providers: 50% up to $600/day+     Non-Preferred Providers: 50% of up to $600/day +
                                       excess charges over $600/day                     excess charges over $600/day                      excess charges over $600/day                      excess charges over $600/day

                                           Preferred Providers: 20%                         Preferred Providers: 30%                            $250/surgery + 25%                              Preferred Providers: 20%
     Outpatient Surgery
                                Non-Preferred Providers: 40% up to $600/day+     Non-Preferred Providers: 50% up to $600/day+      Non-Preferred Providers: 50% up to $600/day+     Non-Preferred Providers: 50% of up to $600/day +
           (ASC)
                                       excess charges over $600/day                     excess charges over $600/day                      excess charges over $600/day                      excess charges over $600/day

     Emergency Room
   (Not resulting in direct                      $100 + 20%                                       $100 + 30%                                         $100 + 25%                                        $100 + 20%
         admission)
Calendar-Year Brand-Name
                                               $150/member                                       $250/member                                       $250/member                                       $500/member
     Drug Deductible
                                                                                                                                                                                                     $15 Generic drug
                                             $10 Generic drug                                  $10 Generic drug                                  $10 Generic drug                   Preferred Providers only. Non-Preferred Providers
                                                                                                                                                                                                       not covered.
                                                                                                                                                                                    $30 Formulary brand-name drug or (30% of Blue
                                                                                                                                                                                        Shield Life contracted rate, whichever is
  Retail Drug Copayments              $30 Formulary brand-name drug                     $30 formulary brand-name drug                     $30 Formulary brand-name drug
                                                                                                                                                                                    greater). Preferred Providers only. Non-Preferred
                                                                                                                                                                                                  Providers not covered.
                                                                                                                                                                                    $50 Non-formulary brand-name drug or (50% of
                                    $50 Non-formulary brand-name drug                $50 Non-formulary brand-name drug                 $50 Non-formulary brand-name drug             Blue Shield Life contracted rate, whichever is
                                                                                                                                                                                    greater). Preferred Providers only. Non-Preferred
                                                                                                                                                                                                 Providers not covered.
  Note 1: This document is only a summary for informational purposes. It is not a contract. Please refer to the Certificate of Insurance/Group Policy or Evidence of Coverage/Plan Contract for the exact terms and conditions of
  coverage. Benefits are subject to modification by Blue Shield for subsequently enacted state or federal legislation. Plans 750 Value, 1000 Value, 1500 Value, 2000 Value and Shield Savings 1800/3600 are pending regulatory
  approval. Note 2: *Plan Underwritten by Blue Shield of California Life & Health Insurance Company. Note 3: **Employees and all enrolled dependents must live or work in the specified service area. The service area for Local
                              Access+ HMO plans includes portions of Los Angeles, Orange, San Diego, San Bernardino, and Riverside Counties as described in the Benefit Summary Guide A16609 .
                                                                      Small Group Plan Comparison for XYZ Group with an Effective Date of 7/1/2009
                                   The table below can help you choose the Blue Shield coverage that's right for you. Please remember, this side-by-side comparison is only a brief overview.
                                                                                Questions? Please contact ABC Producer at (999) 999-9999
                                Shield Spectrum PPO Plan 500 Shield Spectrum PPO Plan 750                                                 Shield Spectrum PPO Plan                               Shield Spectrum PPO Plan                              Shield Spectrum PPO Plan
                                           Value*                       Value*                                                                   1000 Value*                                            1500 Value*                                           2000 Value*
                                            Preferred Providers                               Preferred Providers                                    Preferred Providers                                   Preferred Providers                                    Preferred Providers
                                          Non-Preferred Providers                           Non-Preferred Providers                                Non-Preferred Providers                               Non-Preferred Providers                                Non-Preferred Providers

Copayment Percentage/Co-                  Preferred Providers: 30%                           Preferred Providers: 30%                              Preferred Providers: 30%                               Preferred Providers: 30%                              Preferred Providers: 35%
      pay Amount                        Non-Preferred Providers: 50%                       Non-Preferred Providers: 50%                          Non-Preferred Providers: 50%                           Non-Preferred Providers: 50%                          Non-Preferred Providers: 50%

     Lifetime Maximum                            $6,000,000                                          $6,000,000                                            $6,000,000                                             $6,000,000                                            $6,000,000

  Calendar-Year Medical
                                             $500/$1,000/$1,500                       All Providers Combined: $750/member
        Deductible                                                                                                                         All Providers Combined: $1,000/member                 All Providers Combined: $1,500/member                  All Providers Combined: $2,000/member
                                        (Individual/2-Persons/Family)
    (Individual/Family)
                                                                                     Preferred Providers: $4,000 per member                  Preferred Providers: $4,000/member                    Preferred Providers: $4,500/member                    Preferred Providers: $5,000/member
Calendar-Year Copayment                                                             Non-Preferred Providers: Charges for non-             Non-Preferred Providers: Charges for non-             Non-Preferred Providers: Charges for non-            Non-Preferred Providers: $10,000/member
                                   Preferred Providers: $5,000/member
         Maximum                                                                     emergency services received from non-                 emergency services received from non-                 emergency services received from non-                 (Out-of-pocket copayment maximum
                                 Non-Preferred Providers: $10,000/member
    (Individual/Family)                                                            preferred providers do not count toward the           preferred providers do not count toward the           preferred providers do not count toward the        accumulate separately for preferred and non-
                                                                                  calendar-year copayment maximum and are               calendar-year copayment maximum and are               calendar-year copayment maximum and are                             preferred providers)
                                                                                                                                                                                                                                                    Preferred Providers: $40/visit - first 2 visits/year
                                                                                                                                                                                                                                                   (not subject to the calendar year deductible)
                                                                                                                                                                                                                                                   subsequent visits member pays 100% until the
                                                                                                                                                                                                                                                    calendar-year copayment maximum is met;
                                                                                             Preferred Providers: $15/visit                        Preferred Providers: $20/visit                        Preferred Providers: $30/visit
                                                                                                                                                                                                                                                  once the calendar-year copayment maximum
                                        Preferred Providers: $45/visit          Limit 3 visits/year. Subsequent visits are subject to Limit 3 visits/year. Subsequent visits are subject to Limit 3 visits/year. Subsequent visits are subject to
        Office Visits                                                                                                                                                                                                                                      is met, Blue Shield Life pays 100%
                                        Non-Preferred Providers: 50%                        the calendar year deductible                          the calendar year deductible                          the calendar year deductible
                                                                                             Non-Preferred Providers: 50%                          Non-Preferred Providers: 50%                          Non-Preferred Providers: 50%
                                                                                                                                                                                                                                                   Non-Preferred Providers: 50% - first 2 visits/year
                                                                                                                                                                                                                                                   (not subject to the calendar year deductible)
                                                                                                                                                                                                                                                   subsequent visits member pays 100% until the
                                                                                                                                                                                                                                                    calendar-year copayment maximum is met;
                                                                                                                                                                                                                                                              Preferred Providers: $40/visit
                                       Preferred Providers: $45/visit                        Preferred Providers: $15/visit                        Preferred Providers: $20/visit                        Preferred Providers: $30/visit
      Preventive Care                                                                                                                                                                                                                              (not subject to the calendar year deductible)
                                   Non-Preferred Providers: Not Covered               Non-Preferred Providers: Not Covered                  Non-Preferred Providers: Not Covered                  Non-Preferred Providers: Not Covered
                                                                                                                                                                                                                                                   Non-Preferred Providers: Not Covered
                                   Preferred Providers: $500/admit + 30%             Preferred Providers: $500/admit + 30%                Preferred Providers: $500/admit + 30%                   Preferred Providers: $1,000/year + 30%          Preferred Providers: $1,000/admit + 35%
  Inpatient Hospitalization
                                Non-Preferred Providers: 50% up to $600/day+      Non-Preferred Providers: 50% up to $600/day+         Non-Preferred Providers: 50% up to $600/day +         Non-Preferred Providers: 50% of up to $600/day + Non-Preferred Providers: 50% of up to $600/day +
     Services (Facility)
                                       excess charges over $600/day                      excess charges over $600/day                         excess charges over $600/day                            excess charges over $600/day                    excess charges over $600/day


                                  Preferred Providers: $250/surgery + 30%           Preferred Providers: $250/surgery + 30%               Preferred Providers: $250/surgery + 30%                Preferred Providers: $500/surgery + 30%          Preferred Providers: $500/surgery + 35%
Outpatient Surgery (Hospital)   Non-Preferred Providers: 50% up to $600/day+      Non-Preferred Providers: 50% up to $600/day+         Non-Preferred Providers: 50% up to $600/day +         Non-Preferred Providers: 50% of up to $600/day + Non-Preferred Providers: 50% of up to $600/day +
                                       excess charges over $600/day                      excess charges over $600/day                         excess charges over $600/day                           excess charges over $600/day                     excess charges over $600/day

                                           Preferred Providers: 30%                          Preferred Providers: 30%                             Preferred Providers: 30%                                 $250/surgery + 30%                               $250/surgery + 35%
     Outpatient Surgery
                                Non-Preferred Providers: 50% up to $600/day+      Non-Preferred Providers: 50% up to $600/day+         Non-Preferred Providers: 50% up to $600/day +         Non-Preferred Providers: 50% of up to $600/day + Non-Preferred Providers: 50% of up to $600/day +
           (ASC)
                                       excess charges over $600/day                      excess charges over $600/day                         excess charges over $600/day                           excess charges over $600/day                     excess charges over $600/day

     Emergency Room
                                                                                                                                                                                                                                                                       $100 + 35%
   (Not resulting in direct                      $100 + 30%                                         $100 + 30%                                             $100 + 30%                                            $100 + 30%
                                                                                                                                                                                                                                                     (not subject to the calendar year deductible)
         admission)
Calendar-Year Brand-Name
                                               $250/member                                        $250/member                                                 None                                                  None                                                   None
     Drug Deductible

                               $15 Generic drug Preferred Providers only. Non-                     $15 Generic drug                                     $15 Generic drug                                $15 Generic drug                                 $15 Generic drug
                                        Preferred Providers not covered.           Preferred Providers only. Non-Preferred Providers Preferred Providers only. Non-Preferred Providers Preferred Providers only. Non-Preferred Providers Preferred Providers only. Non-Preferred Providers
                                                                                                      not covered.                                        not covered.                                    not covered.                                     not covered.
                                 $30 Formulary brand-name drug (30% of Blue        $30 Brand-name drug or (30% of Blue Shield Life $30 Formulary brand-name drug or (30% of Blue $30 Formulary brand-name drug or (30% of Blue
                              Shield Life contracted rate, whichever is greater) contracted rate, whichever is greater) Preferred          Shield Life contracted rate, whichever is   Shield Life contracted rate, whichever is greater)
  Retail Drug Copayments                                                                                                                                                                                                                  Formulary brand-name drugs are not covered
                               Preferred Providers only. Non-Preferred Providers      Providers only. Non-Preferred Providers not       greater). Subject to $1,000 maximum on brand-     Subject to $500 maximum on brand-name
                                                  not covered.                                          covered.                          name drugs, per person, per calendar year.    drugs, per person, per calendar year. Preferred
                                 $50 Non-formulary brand-name drug (50% of                                                                          Preferred Providers only.                            Providers only.
                                                                                     Non-formulary drugs are not covered (unless         Non-formulary drugs are not covered (unless     Non-formulary drugs are not covered (unless
                                 Blue Shield Life contracted rate, whichever is                                                                                                                                                               Non-formulary drugs are not covered
                                                                                   prior authorization is obtained from Blue Shield) prior authorization is obtained from Blue Shield) prior authorization is obtained from Blue Shield)
                               greater) Preferred Providers only. Non-Preferred
                                             Providers not covered.
Note 1: This document is only a summary for informational purposes. It is not a contract. Please refer to the Certificate of Insurance/Group Policy or Evidence of Coverage/Plan Contract for the exact terms and conditions of coverage. Benefits are subject to modification by Blue
    Shield for subsequently enacted state or federal legislation. Plans 750 Value, 1000 Value, 1500 Value, 2000 Value, Shield Savings 1800/3600, and Shield Savings 2000/4000 are pending regulatory approval. Note 2: *Plan Underwritten by Blue Shield of California Life & Health
Insurance Company. Note 3: **Employees and all enrolled dependents must live or work in the specified service area. The service area for Local Access+ HMO plans includes portions of Los Angeles, Orange, San Diego, San Bernardino, and Riverside Counties as described in the
                                                                                                                                Benefit Summary Guide A16609.
                                                                  Small Group Plan Comparison for XYZ Group with an Effective Date of 7/1/2009
                               The table below can help you choose the Blue Shield coverage that's right for you. Please remember, this side-by-side comparison is only a brief overview.                                                                                             The table below can help you ch
                                                                            Questions? Please contact ABC Producer at (999) 999-9999
                                                                                       Shield Savings                             Shield Savings                                                             Shield Savings
                                  Shield Savings 1800/3600*                                                                                                        Shield Savings 2500*                                                      Shield Savings 4800*
                                                                                        2000/4000*                                  2250/4500                                                                 3000/6000*
                                            Preferred Providers                         Preferred Providers                        Preferred Providers                   Preferred Providers                  Preferred Providers                  Preferred Providers
                                          Non-Preferred Providers                     Non-Preferred Providers                    Non-Preferred Providers               Non-Preferred Providers              Non-Preferred Providers              Non-Preferred Providers
                                                                                                                                                                                                                                               Preferred Providers: 0% (after
Copayment Percentage/Co-                  Preferred Providers: 0%                     Preferred Providers: 0%                    Preferred Providers: 20%              Preferred Providers: 20%             Preferred Providers: 0%                                               Copayment Percentage/Co-
                                                                                                                                                                                                                                                       deductible)
      pay Amount                        Non-Preferred Providers: 30%                Non-Preferred Providers: 30%               Non-Preferred Providers: 50%          Non-Preferred Providers: 50%         Non-Preferred Providers: 30%                                                  pay Amount
                                                                                                                                                                                                                                               Non-Preferred Providers: 50%

      Lifetime Maximum                            $6,000,000                                  $6,000,000                                $6,000,000                            $6,000,000                           $6,000,000                           $6,000,000                    Lifetime Maximum

                                                                                                                                                                 Preferred Providers: $2,500/$5,000     Preferred Providers: $3,000/$6,000   Preferred Providers: $4,800/$9,600     Calendar-Year Medical
  Calendar-Year Medical              Preferred Providers: $1,800/$3,600          Preferred Providers: $2,000/$4,000
                                                                                                                           All Providers Combined: $2,250/$4,500      Non-Preferred Providers:               Non-Preferred Providers:             Non-Preferred Providers:                Deductible
Deductible (Individual/Family)     Non-Preferred Providers: $1,800/$3,600      Non-Preferred Providers: $2,000/$4,000
                                                                                                                                                                           $2,500/$5,000                          $3,000/$6,000                        $4,800/$9,600                  (Individual/Family)

                                                                                                                                                                                                                                             Preferred Providers: $4,800/$9,600
                                                                                                                                                                   Preferred Providers: $4,000/$8,000   Preferred Providers: $3,000/$6,000
 Calendar-Year Copayment             Preferred Providers: $1,800/$3,600          Preferred Providers: $2,000/$4,000                                                                                                                               Non-Preferred Providers:       Calendar-Year Copayment
                                                                                                                           All Providers Combined: $4,500/$9,000        Non-Preferred Providers:             Non-Preferred Providers:
Maximum (Individual/Family)        Non-Preferred Providers: $3,600/$7,200      Non-Preferred Providers: $4,000/$8,000                                                                                                                                 $10,000/$20,000           Maximum (Individual/Family)
                                                                                                                                                                            $10,000/$20,000                      $6,000/$12,000




                                                                                                                                                                                                                                               Preferred Providers: 0% (after
                                          Preferred Providers: 0%                     Preferred Providers: 0%                    Preferred Providers: 20%              Preferred Providers: 20%             Preferred Providers: 0%
         Office Visits                                                                                                                                                                                                                                 deductible)                        Office Visits
                                        Non-Preferred Providers: 30%                Non-Preferred Providers: 30%               Non-Preferred Providers: 50%          Non-Preferred Providers: 50%         Non-Preferred Providers: 30%
                                                                                                                                                                                                                                               Non-Preferred Providers: 50%




                                   Preferred Providers: $0/visit (deductible   Preferred Providers: $0/visit (deductible       Preferred Providers: $35/visit        Preferred Providers: $35/visit     Preferred Providers: $0/visit           Preferred Providers: $0/visit
       Preventive Care                             waived)                                     waived)                             (deductible waived)                    (deductible waived)              (deductible waived)                     (deductible waived)                  Preventive Care
                                    Non-Preferred Providers: Not Covered        Non-Preferred Providers: Not Covered       Non-Preferred Providers: Not Covered      Non-Preferred Providers: Not      Non-Preferred Providers: Not            Non-Preferred Providers: Not
                                                                                                                                                                                Covered                          Covered                                 Covered
                                                                                                                                                                                                                                               Preferred Providers: 0% (after
                                          Preferred Providers: 0%                     Preferred Providers: 0%                    Preferred Providers: 20%               Preferred Providers: 20%          Preferred Providers: 0%
   Inpatient Hospitalization        Non-Preferred Providers: 30% of up to       Non-Preferred Providers: 30% of up to      Non-Preferred Providers: 50% of up to    Non-Preferred Providers: 50% of Non-Preferred Providers: 30% of up                 deductible)                  Inpatient Hospitalization
      Services (Facility)             $600/day + excess charges over              $600/day + excess charges over             $600/day + excess charges over        up to $600/day + excess charges to $600/day + excess charges over          Non-Preferred Providers: 50% of          Services (Facility)
                                                 $600/day                                    $600/day                                    $600/day                            over $600/day                       $600/day                    up to $600/day + excess charges
                                          Preferred Providers: 0%                     Preferred Providers: 0%                    Preferred Providers: 20%               Preferred Providers: 20%         Preferred Providers: 0%                      over $600/day
                                                                                                                                                                                                                                               Preferred Providers: 0% (after
                                    Non-Preferred Providers: 30% of up to       Non-Preferred Providers: 30% of up to      Non-Preferred Providers: 50% of up to    Non-Preferred Providers: 50% of Non-Preferred Providers: 30% of up                 deductible)
Outpatient Surgery (Hospital)                                                                                                                                                                                                                                                 Outpatient Surgery (Hospital)
                                      $600/day + excess charges over              $600/day + excess charges over             $600/day + excess charges over        up to $600/day + excess charges to $600/day + excess charges over          Non-Preferred Providers: 50% of
                                                 $600/day                                    $600/day                                    $600/day                            over $600/day                      $600/day                     up to $600/day + excess charges
                                          Preferred Providers: 0%                     Preferred Providers: 0%                    Preferred Providers: 10%               Preferred Providers: 10%         Preferred Providers: 0%                      over $600/day
                                                                                                                                                                                                                                               Preferred Providers: 0% after
     Outpatient Surgery             Non-Preferred Providers: 30% of up to       Non-Preferred Providers: 30% of up to      Non-Preferred Providers: 50% of up to    Non-Preferred Providers: 50% of Non-Preferred Providers: 30% of up                  deductible                    Outpatient Surgery
           (ASC)                      $600/day + excess charges over              $600/day + excess charges over             $600/day + excess charges over        up to $600/day + excess charges to $600/day + excess charges over          Non-Preferred Providers: 50% of               (ASC)
                                                 $600/day                                    $600/day                                    $600/day                            over $600/day                      $600/day                     up to $600/day + excess charges
      Emergency Room                                                                                                                                                                                                                                                                   Emergency Room
    (Not resulting in direct                          $0                                          $0                                    $100 + 20%                            $100 + 20%                                0                                    0                       (Not resulting in direct
          admission)                                                                                                                                                                                                                                                                       admission)
 Calendar-Year Brand-Name                                                                                                                                                                                                                                                         Calendar-Year Brand-Name
                                                    None                                        None                                       None                                  None                                 None                                 None
      Drug Deductible                                                                                                                                                                                                                                                                  Drug Deductible

                                               $0/prescription                             $0/prescription                           $10 Generic drug                      $10 Generic drug                      $0/prescription                     0% Generic Drug

                                                                                                                                                                   $30 Formulary brand-Name Drug
                                                                                                                            $30 Formulary brand-Name Drug or
                                                                                                                                                                       or (30% of Blue Shield Life
   Retail Drug Copayments                      $0/prescription                             $0/prescription                  (30% of Blue Shield contracted rate,                                                 $0/prescription             0% Formulary brand-name Drug          Retail Drug Copayments
                                                                                                                                                                    contracted rate, whichever is
                                                                                                                                   whichever is greater)
                                                                                                                                                                                greater)
                                                                                                                          $50 Non-Formulary brand-name drug or $50 Non-Formulary brand-name
                                                                                                                                                                                                                                       0% Non-Formulary brand-name
                                               $0/prescription                             $0/prescription                  (50% of Blue Shield contracted rate,   drug or (50% of Blue Shield Life         $0/prescription
                                                                                                                                                                                                                                                     drug
                                                                                                                                    whichever is greater)          contracted rate, whichever is
                                                                                                                                                                                                                                                                                      Note 1: This document is only a summary for
                                                                                                                                                                              greater)
   Note 1: This document is only a summary for informational purposes. It is not a contract. Please refer to the Certificate of Insurance/Group Policy or Evidence of Coverage/Plan Contract for the exact terms and conditions of coverage. Benefits are subject to                conditions of coverage. Benefits are subject to
  modification by Blue Shield for subsequently enacted state or federal legislation. Plans 750 Value, 1000 Value, 1500 Value, 2000 Value, Shield Savings 1800/3600, and Shield Savings 2000/4000 are pending regulatory approval. Note 2: *Plan Underwritten by Blue              Shield Savings 2000/4000 are pending regulator
   Shield of California Life & Health Insurance Company. Note 3: **Employees and all enrolled dependents must live or work in the specified service area. The service area for Local Access+ HMO plans includes portions of Los Angeles, Orange, San Diego, San                    in the specified service area. The service area
                                                                                          Bernardino, and Riverside Counties as described in the Benefit Summary Guide A16609.
                                       Small Group Plan Comparison for XYZ Group with an Effective Date of 7/1/2009
    The table below can help you choose the Blue Shield coverage that's right for you. Please remember, this side-by-side comparison is only a brief overview.
                                                 Questions? Please contact ABC Producer at (999) 999-9999

                                     Active Choice Plan 750 SG*                                         Active Choice Plan 500 SG*                                      Added Advantage POS Plan
                                                Preferred Providers                                                Preferred Providers                                           Level I HMO Plan Provider
                                              Non-Preferred Providers                                            Non-Preferred Providers                                         Level II PPO Plan Provider
                                                                                                                                                                                 Level I HMO Plan Provider: N/A
                                               Preferred Providers: 20%                                           Preferred Providers: 30%
                                                                                                                                                                          Level II PPO Plan Preferred Provider: 30%
                                             Non-Preferred Providers: 40%                                       Non-Preferred Providers: 50%
                                                                                                                                                                        Level II PPO Plan Non- Preferred Provider: 30%

                                                      $6,000,000                                                         $6,000,000                                                       $2,000,000
                                                                                                                                                                                Level I HMO Plan Provider: None
                                                        None                                                               None                                      Level II PPO Plan Provider: $500/$1,000 (all providers
                                                                                                                                                                                          combined)


                                                                                                                                                                          Level I HMO Plan Provider: $2,500/$5,000
                                         Preferred Providers: $5,000/$10,000                                Preferred Providers: $5,000/$10,000
                                                                                                                                                                        Level II PPO Plan Provider: $5,000/$10,000 (all
                                       Non-Preferred Providers: $10,000/$20,000                           Non-Preferred Providers: $10,000/$20,000
                                                                                                                                                                                    providers combined)




                                                       Category 1                                                         Category 1
                                            First Dollar Services Coverage:                                    First Dollar Services Coverage:
                                                     $750 Individual                                                    $500 Individual                                      Level I HMO Plan Provider: $25/visit
                                                      $1,500 Family                                                      $1,000 Family                                    Level II PPO Plan Preferred Provider: 30%
                                           Then the member is responsible                                     Then the member is responsible                            Level II PPO Plan Non-Preferred Provider: 30%
                                           for charges up to the calendar                                     for charges up to the calendar
                                              year copayment maximum                                             year copayment maximum



                                                                                                                                                                             Level I HMO Plan Provider: No charge
                                                    Category 1                                                         Category 1
                                                                                                                                                                            Level II PPO Plan Provider: Not Covered
                                         Same as Office Visits section above                                Same as Office Visits section above
                                                                                                                                                                        Level II PPO Plan Non-Preferred Provider: Not
                                                      Category 2                                                                                                                            Covered
                                                                                                                        Category 2                                           Level I HMO Plan Provider: $500/admit
                                         Preferred Provider: $500/admit +20%                               Preferred Provider: $500/admit +30%                              Level II PPO Plan Preferred Provider: 30%
                              Non-Preferred Provider coinsurance: 40% up to $600/day +       Non-Preferred Provider coinsurance: 50% up to $600/day + excess        Level II PPO Plan Non-Preferred Provider: 30% of up to
                                            excess charges over $600/day                                          charges over $600/day                                   $600/day + excess charges over $600/day
                                                     Category 2                                                         Category 2                                          Level I HMO Plan Provider: $500/surgery
                                       Preferred Provider: $400/surgery + 20%                             Preferred Provider: $400/surgery + 30%                            Level II PPO Plan Preferred Provider: 30%
                              Non-Preferred Provider coinsurance: 40% up to $600/day +       Non-Preferred Provider coinsurance: 50% up to $600/day + excess        Level II PPO Plan Non-Preferred Provider: 30% of up to
                                           excess charges over $600/day                                           charges over $600/day                                   $600/day + excess charges over $600/day
                                                                                                                                                                            Level I HMO Plan Provider: $350/surgery
                                       Preferred Providers: $250/surgery + 20%                            Preferred Providers: $250/surgery + 30%
                                                                                                                                                                            Level II PPO Plan Preferred Provider: 30%
                              Non-Preferred Provider coinsurance: 40% up to $600/day +       Non-Preferred Provider coinsurance: 50% up to $600/day + excess
                                                                                                                                                                    Level II PPO Plan Non-Preferred Provider: 30% of up to
                                           excess charges over $600/day                                           charges over $600/day
                                                                                                                                                                          $600/day + excess charges over $600/day
                                                                                                                                                                              Level I HMO Plan Provider: $100/visit
                                                     Category 2                                                         Category 2
                                                                                                                                                                              Level II PPO Plan Provider: $100/visit
                                                     $100 + 20%                                                         $100 + 30%
                                                                                                                                                                     Level II PPO Plan Non-Preferred Provider: $100/visit
                                                     Category 3                                                         Category 3                                        Level I HMO Plan Provider: $150/member
                                                    $250/member                                                        $500/member

                                                     Category 3                                                         Category 3
                                                                                                                                                                        Level I HMO Plan Provider: $15 Generic drug
                                                  $15 Generic drug                                                   $15 Generic drug

                                                     Category 3                                                         Category 3
                                                                                                                                                                       Level I HMO Plan Provider: $30 Formulary brand-
                                Formulary brand-name Drug: Greater of $30 copay (or          Formulary brand-name Drug: Greater of $30 copay (or 30% of Blue
                                                                                                                                                                                         name drug
                                       30% of Blue Shield Life contracted rate)                                Shield Life contracted rate)

                                                        Category 3                                                           Category 3
                                                                                                                                                                        Non-formulary drugs are not covered (unless prior
                                 Non-formulary brand-name drug: Greater of $50 copay         Non-formulary brand-name drug: Greater of $50 copay (or 50% of Blue
                                                                                                                                                                           authorization is obtained from Blue Shield)
                                       (or 50% of Blue Shield Life contracted rate)                                 Shield Life contracted rate)
    Note 1: This document is only a summary for informational purposes. It is not a contract. Please refer to the Certificate of Insurance/Group Policy or Evidence of Coverage/Plan Contract for the exact terms and
  conditions of coverage. Benefits are subject to modification by Blue Shield for subsequently enacted state or federal legislation. Plans 750 Value, 1000 Value, 1500 Value, 2000 Value, Shield Savings 1800/3600, and
Shield Savings 2000/4000 are pending regulatory approval. Note 2: *Plan Underwritten by Blue Shield of California Life & Health Insurance Company. Note 3: **Employees and all enrolled dependents must live or work
 in the specified service area. The service area for Local Access+ HMO plans includes portions of Los Angeles, Orange, San Diego, San Bernardino, and Riverside Counties as described in the Benefit Summary Guide
                                                                                                            A16609.

				
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