Blue Shield Evidence of Coverage and Disclosure Form by kzk85286

VIEWS: 6 PAGES: 80

									                             PPO Plan

                             Blue Shield Evidence of Coverage
                             and Disclosure Form

                             City of Anaheim
                             Group Number: 977662
                             80%/70% Plan
                             Effective Date: January 1, 2004




Visit us at mylifepath.com
                  Group
                                 Evidence of Coverage
                                 and Disclosure Form




                                         City of Anaheim
                                      Preferred Provider Plan
                                     Effective Date: January 1, 2004




                                                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 under-
stand 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 Customer Service at the address or telephone number listed at the back 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; sterilization, including tubal ligation at the
time of labor and delivery; infertility treatments; or abortion. You should obtain more information be-
fore you enroll. Call your prospective doctor, medical group, independent practice association, or clinic,
or call the health plan at Blue Shield’s Customer Service telephone number listed at the back of this
booklet to ensure that you can obtain the health care services that you need.




ppo (7/03)
TABLE OF CONTENTS
SUMMARY OF BENEFITS ................................................................................................................................5
INTRODUCTION TO THE BLUE SHIELD OF CALIFORNIA PREFERRED PLAN ....................................................9
YOUR BLUE SHIELD OF CALIFORNIA PREFERRED PLAN AND HOW TO USE IT .............................................10
   The Blue Shield of California Preferred Plan ......................................................................................10
   Blue Shield of California's Preferred Providers...................................................................................10
   How to Receive Services .....................................................................................................................11
DEFINITIONS ...............................................................................................................................................12
ELIGIBILITY ................................................................................................................................................19
EFFECTIVE DATE OF COVERAGE .................................................................................................................20
RENEWAL OF GROUP HEALTH SERVICE CONTRACT....................................................................................21
PREPAYMENT FEE .......................................................................................................................................22
PLAN CHANGES...........................................................................................................................................22
MEDICAL NECESSITY ..................................................................................................................................22
UTILIZATION REVIEW .................................................................................................................................22
SECOND MEDICAL OPINION POLICY ...........................................................................................................23
HEALTH EDUCATION AND HEALTH PROMOTION SERVICES ........................................................................23
LIFEPATH ADVISERS ...................................................................................................................................23
BLUE SHIELD ONLINE .................................................................................................................................23
BENEFITS MANAGEMENT PROGRAM ...........................................................................................................23
   Preservice Review................................................................................................................................24
   Prior Authorization ..............................................................................................................................24
   Preadmission Review – Hospital Admissions ....................................................................................25
   Emergency Admission Notification.....................................................................................................26
   Hospital Inpatient Utilization Review .................................................................................................26
   Discharge Planning ..............................................................................................................................27
   Care Management ................................................................................................................................27
DEDUCTIBLE ...............................................................................................................................................27
ADDITIONAL AND REDUCED PAYMENTS FOR FAILURE TO USE
THE BENEFITS MANAGEMENT PROGRAM ...................................................................................................27
MAXIMUM AGGREGATE PAYMENT AMOUNT ..............................................................................................28
PAYMENT ....................................................................................................................................................28
   Maximum Calendar Year Copayment Responsibility .........................................................................33
   Continuity of Care by a Terminated Provider......................................................................................34
   Preferred Provider Benefit Features.....................................................................................................34
PRINCIPAL BENEFITS AND COVERAGES (COVERED SERVICES) ...................................................................35
   Hospital Benefits..................................................................................................................................35
   Skilled Nursing Facilities Benefits ......................................................................................................36
   Surgical Benefits..................................................................................................................................36
   Ambulatory Surgical Benefits..............................................................................................................36
   Medical Benefits ..................................................................................................................................37
   Preventive Care Benefits......................................................................................................................37
   Outpatient or Out-of-Hospital X-ray and Laboratory Benefits............................................................38
   Chemotherapy Benefits........................................................................................................................38
   Acupuncture Benefits...........................................................................................................................38
   Prosthetic Appliances and Home Medical Equipment Benefits ..........................................................38
   Orthoses Benefits .................................................................................................................................39
   Diabetes Care .......................................................................................................................................39
   Pregnancy Benefits ..............................................................................................................................40
   Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits.................................40

                                                                            -2-
TABLE OF CONTENTS
   Reconstructive Surgery........................................................................................................................41
   Chiropractic Services ...........................................................................................................................41
   Outpatient Physical Medicine Benefits................................................................................................41
   Speech Therapy Benefits .....................................................................................................................41
   Transplant Benefits ..............................................................................................................................42
   Home Health Care/ Home Infusion Care Benefits, and PKU Related Formulas and
   Special Food Products..........................................................................................................................43
   Hospice Program Services ...................................................................................................................44
   Ambulance Benefits.............................................................................................................................47
   Podiatric Services.................................................................................................................................47
   Clinical Trial for Cancer ......................................................................................................................47
   Well Baby Care....................................................................................................................................47
   Hearing Aid Services ...........................................................................................................................48
   Mental Health and Substance Abuse Benefits .....................................................................................48
   Substance Abuse Benefits....................................................................................................................48
PRINCIPAL LIMITATIONS, EXCEPTIONS, EXCLUSIONS AND REDUCTIONS ....................................................48
   General Exclusions ..............................................................................................................................48
   Medical Necessity Exclusion...............................................................................................................51
   Pre-Existing Conditions .......................................................................................................................51
   Exclusion for Duplicate Coverage .......................................................................................................52
   Exception for Other Coverage .............................................................................................................53
   Claims Review .....................................................................................................................................53
   Reductions............................................................................................................................................53
GENERAL PROVISIONS ................................................................................................................................53
   Coordination of Benefits......................................................................................................................53
   Continuation of Group Coverage.........................................................................................................55
   Continuation of Group Coverage after COBRA and/or Cal-COBRA.................................................59
   Individual Conversion Plan..................................................................................................................60
   Extension of Benefits...........................................................................................................................60
   Termination of Benefits .......................................................................................................................61
   Reinstatement, Cancellation and Rescission Provisions......................................................................62
   Liability of Subscribers in the Event of Non-Payment by Blue Shield ...............................................62
   Non-Assignability................................................................................................................................63
   Customer Service .................................................................................................................................63
   Grievance Process................................................................................................................................64
   Department of Managed Health Care Review .....................................................................................65
   Public Policy Participation Procedure .................................................................................................65
   Confidentiality of Personal and Health Information............................................................................66
   Independent Contractors ......................................................................................................................66
BLUE SHIELD OF CALIFORNIA VISION PLAN ...............................................................................................67




                                                                           -3-
This booklet constitutes only a summary of the health plan. The health plan contract must be
consulted to determine the exact terms and conditions of coverage.

The group contract is on file with your employer and a copy will be furnished upon request.
This is a Preferred Provider plan. Benefits, particularly the payment provisions, differ from other
Blue Shield of California plans. Be sure you understand the benefits of this plan before Services
are received.

                                             NOTICE
 Please read this Evidence of Coverage and Disclosure Form booklet carefully to be sure you
 understand the benefits, exclusions and general provisions. It is your responsibility to keep in-
 formed about any changes in your health coverage.
 Should you have any questions regarding your Blue Shield of California health plan, see your
 employer or contact any of the Blue Shield of California offices listed on the last page of this
 booklet.




                                          IMPORTANT
 No Person has the right to receive the benefits of this plan for Services or supplies furnished
 following termination of coverage, except as specifically provided under the Extension of Bene-
 fits provision, and when applicable, the Continuation of Group Coverage provision in this
 booklet.
 Benefits of this plan are available only for Services and supplies furnished during the term it is
 in effect and while the individual claiming benefits is actually covered by this group contract.

 Benefits may be modified during the term of this plan as specifically provided under the terms
 of the group contract or upon renewal. If benefits are modified, the revised benefits (including
 any reduction in benefits or the elimination of benefits) apply for Services or supplies furnished
 on or after the effective date of modification. There is no vested right to receive the benefits of
 this plan.




                                                 -4-
SUMMARY OF BENEFITS
Preferred Provider Plan

 DEDUCTIBLE

 Subscriber’s Calendar Year Deductible                                              For Illness/
                                                                                    Accidental Injury
  The Calendar Year deductible does not apply to:
                                                                                    $1,000 per Person
       Preventive Care Benefits for the following Services:
             Annual Health Appraisal Exam Services including,                       $3,000 per Family
                 annual physical examination,
                 routine laboratory Services,
                 mammography and Papanicolaou’s test;
             Well Baby Care office visits;
             the Preventive Care Sigmoidoscopy;
       Family Planning counseling and consultation Services;
       Preferred Physician office visits including:
             Mammography and Papanicolaou’s Test. However, other covered
             Services received during or in connection with a Preferred Physician
             office visit are subject to the Calendar Year deductible;
       Emergency Room Facility Services not resulting in an admission.


 ADDITIONAL AND REDUCED PAYMENT(S)

 Additional and Reduced Payment(s)
 Refer to the Benefits Management Program for any Additional Payments and Re-
 duced Payments which may apply.




                                                     -5-
SUMMARY OF BENEFITS
Preferred Provider Plan

 BLUE SHIELD’S PAYMENT PERCENTAGE

 Physicians (except for Hospice Program Services)
       Participating Physicians                                                              80%
       Non-Participating Physicians                                                          70%

 Hospitals (except for Hospice Program Services)
       Preferred Hospitals — Emergency and Non-Emergency Services                            80%
       Non-Preferred Hospitals
               Emergency                                                                     80%
               Non-Emergency                                                                70%*
                                                                                          (*Payment
                                                                                     not to exceed $420
                                                                                     per Person per day.)
 Alternate Care Services Providers
 Includes Home Medical Equipment suppliers, individual certified orthotists,
 prosthetists, and prosthetist-orthotists.
       Participating Alternate Care Services Providers                                       80%
       Non-Participating Alternate Care Services Providers                                   70%
 Note: for all Services covered under the Orthoses Benefit Subscribers have a
 combined $2,000 per Person per Calendar Year benefit maximum. This maxi-
 mum does not apply to Services covered under the Prosthetic Appliances and
 Home Medical Equipment Benefits or the Diabetes Care benefit.
 Ambulatory Surgery Centers
       Participating Ambulatory Surgery Centers                                              80%
       Non-Participating Ambulatory Surgery Centers                                          70%*
                                                                                          (*Payment
 NOTE: Outpatient ambulatory surgery Services may also be obtained from a
                                                                                      not to exceed $420
 Hospital. Ambulatory surgery Services obtained from a Hospital will be paid at
                                                                                      per Person per day)
 the Preferred or Non-Preferred level as specified in the Hospital section of this
 Summary of Benefits.

 Hearing Aid Services
       Audiological Evaluation                                                                80%
       Hearing Aid and ancillary Equipment                                            100% of the Allow-
                                                                                     able Amount up to a
                                                                                     maximum payment of
                                                                                       $1,000 per Person
                                                                                        every 36 months




                                                     -6-
SUMMARY OF BENEFITS
Preferred Provider Plan
BLUE SHIELD’S PAYMENT PERCENTAGE (CONT.)
     Acupuncture Services
     Benefits are limited to a maximum of 20 visits per Person per Calendar Year
     Preferred Provider                                                                       80%
     Non-Preferred Provider                                                               Not covered
     Chiropractic Services
     Benefits are limited to a maximum of 20 visits per Person per Calendar Year
     Preferred Provider                                                                       80%
     Non-Preferred Provider                                                               Not covered

     Other Providers                                                                          80%
     Home Health Care and Home Infusion Agencies1
         Participating Home Health Care and Home Infusion Agencies                            80%
         Non-Participating Home Health Care and Home Infusion Agencies                Not covered unless
                                                                                      prior authorized by
                                                                                         Blue Shield2.
    Hospice Program Services
    Participating Hospice Agency
         Continuous Home Care provided during a Period of Crisis
         General Inpatient care                                                               80%
         Inpatient Respite Care                                                               80%
         Routine home care                                                                   100%
    Non-Participating Hospice Agency3                                                         100%
                                                                                         Not covered3
                                                                                   unless prior authorized by
                                                                                          Blue Shield
1
      All benefits for home health care, home infusion and home injectable treatment must be prior
      authorized by Blue Shield.
2
      No benefits are provided for Home Health Care Benefits and Home Infusion Therapy Benefits
      by Non-Participating Providers except as may be prior authorized by Blue Shield. If prior
      authorized by Blue Shield, Non-Participating Providers will be reimbursed at a rate deter-
      mined by the agency and Blue Shield, with the Subscriber Copayment at the Participating
      Provider level..
3
      Covered Hospice Services received from Non-Participating Hospice Agencies must be prior
      authorized by Blue Shield. If Blue Shield prior authorizes Hospice services from a Non-
      Participating Hospice Agency, those Hospice Services will be reimbursed at the Participating
      Hospice Agency level.



                                                        -7-
SUMMARY OF BENEFITS
Preferred Provider Plan

 COPAYMENT RESPONSIBILITY

 Subscriber’s maximum Calendar Year copayment for covered Services rendered          $6,000 per Person
 by Preferred Providers (Physician Members, Preferred Hospitals, Participating       per Calendar Year
 Providers), and Other Providers
                                                                                     $18,000 per Family
                                                                                     per Calendar Year

 Subscriber’s maximum Calendar Year copayment for covered Services rendered          $9,000 per Person
 by any combination of Preferred Providers, Non-Preferred Providers, and Other       per Calendar Year
 Providers
                                                                                     $27,000 per Family
                                                                                     per Calendar Year

   The following are not included in the Subscriber’s maximum Calendar Year copayment amount:
   Preventive Care Benefits Services for the Annual routine physical exam (includes eye/ear screenings
   and vaccinations);
   Well baby care office visits and consultations;
   Family Planning counseling and consultation Services;
   Physician office visits and consultations, specialist visits and consultations;
   Emergency Room Facility Services not resulting in an admission;
   The Calendar Year deductible;
   Charges by Non-Preferred Providers in excess of covered amounts;
   Charges in excess of specified benefit maximums;
   Non-Preferred Hospital and Professional Services (except for emergencies);
   Non-Participating Ambulatory Surgery Center Services;
   Additional and Reduced Payments under the Benefits Management Program.

   Note: The Summary of Benefits represents only a brief description of some of the
   benefits. Please read this booklet carefully for a complete description of provisions,
   benefits and exclusions of the plan.




                                                     -8-
INTRODUCTION TO THE BLUE SHIELD OF                        Failure to meet these responsibilities may re-
                                                          sult in your incurring a substantial financial
CALIFORNIA PREFERRED PLAN                                 liability. Some Services may not be covered
If you have questions about your benefits,                unless prior review and other requirements
contact Blue Shield of California before Hos-             are met.
pital or medical Services are received.                   NOTE: Blue Shield will render a decision on
This plan is designed to reduce the cost of               all requests for pre-service review, prior
health care to you, the Subscriber. In order to           authorization and pre-admission review
reduce your costs, much greater responsibility is         within 5 business days from receipt of the re-
placed on you.                                            quest. The treating provider will be notified
                                                          of the decision within 24 hours followed by
You are responsible for following the Blue                written notice to the provider and Subscriber
Shield of California Benefits Management                  within 2 business days of the decision. For
Program including:                                        urgent services in situations in which the rou-
                                                          tine decision making process might seriously
1. Assuring that the Physician or Hospital you            jeopardize the life or health of a Person or
   choose is a Preferred Provider.                        when the Person is experiencing severe pain,
                                                          Blue Shield will respond within 72 hours
2. Obtaining, or assuring that your Physician
                                                          from receipt of the request.
   obtains, Preservice Benefit Determination
   and Certification to determine if contem-
   plated Services are covered.
                                                          Blue Shield of California
                                                          Preferred Providers
3. Obtaining, or assuring that your Physician
   obtains, Blue Shield of California approval 5          The Blue Shield of California Preferred Plan is
   working days before Hospital admission for             specifically designed for you to use Blue Shield
   all non-emergency Inpatient Hospital Serv-             of California Preferred Providers. Preferred
   ices.                                                  Providers include certain Physicians, Hospitals,
                                                          Alternate Care Services Providers, and other
4. Notifying Blue Shield of California within             providers. They are listed in the Preferred Pro-
   24 hours or by the end of the first business           vider directories. It is your obligation to be
   day following emergency admissions.                    sure that the Physician, Hospital, or Alter-
                                                          nate Care Services Provider you choose is a
5. Assuring that you obtain Blue Shield of                Preferred Provider, in case there have been
   California's recommendation regarding sur-             any changes since your Preferred Provider
   gical procedures to be performed on an Out-            directory was published.
   patient basis.
                                                          Blue Shield of California Preferred Providers
6. Obtaining approval from Blue Shield of                 agree to accept Blue Shield of California's pay-
   California for any proposed treatment plan             ment, plus your payment of any applicable de-
   for home care, Home Medical Equipment,                 ductible and copayment, or amounts in excess of
   home infusion therapy, Speech Therapy or               benefit dollar maximums specified, as payment-
   Rehabilitation or Rehabilitative Care.                 in-full for covered Services. This is not true of
                                                          Non-Preferred Providers.
7. Obtaining prior approval for admission into
   an approved Hospice Program as specified               If you go to a Non-Preferred Provider, Blue
   under the Hospice Program Services in the              Shield of California's payment for a service
   Covered Services section.                              by that Non-Preferred Provider may be sub-



                                                    -9-
stantially less than the amount billed. You                BLUE SHIELD OF CALIFORNIA'S
are responsible for the difference between the             PREFERRED PROVIDERS
amount Blue Shield of California pays and
the amount billed by Non-Preferred Provid-                 All Blue Shield of California Physician Mem-
ers. It is therefore to your advantage to ob-              bers are Blue Shield of California Preferred
tain medical and Hospital Services from Pre-               Providers. So are selected Hospitals in your
ferred Providers.                                          community.
If emergency care is needed in a Non-Preferred             Many other healthcare professionals, including
Hospital, payment will be made at the Hospital's           dentists, podiatrists, optometrists, audiologists,
Billed Charge for covered Services, less any ap-           licensed clinical psychologists and marriage,
plicable deductible or copayment. You are re-              family and child counselors are also Preferred
sponsible for notifying Blue Shield of California          Providers. They are all listed in your Preferred
within 24 hours, or by the end of the first busi-          Provider Directories.
ness day following emergency admission at a
Non-Preferred Hospital.                                    Blue Shield of California Preferred Providers
                                                           are working to hold down the costs of health
Directories of Blue Shield of California Pre-              care while maintaining quality care. They agree
ferred Providers located in your area have been            to accept Blue Shield of California's payment,
provided to you. Extra copies are available                plus any deductibles or copayments you may be
from Blue Shield of California. If you do not              responsible for under the terms of your plan, as
have the directories, please contact Blue Shield           payment-in-full for covered Services.
of California immediately and request them at
the telephone number listed on the last page of            USING PREFERRED PROVIDERS SAVES
this booklet.                                              YOU MONEY; USING NON-PREFERRED
                                                           PROVIDERS CAN COST YOU MONEY
YOUR BLUE SHIELD OF CALIFORNIA
                                                           When you receive covered Services from a Pre-
PREFERRED PLAN AND HOW TO USE                              ferred Provider, Blue Shield of California pays
IT                                                         the provider directly, and except for any de-
                                                           ductibles or copayments that may apply, you
THE BLUE SHIELD OF CALIFORNIA                              have no further financial responsibility.
PREFERRED PLAN                                             When you use a Non-Preferred Provider, you
                                                           are responsible for any difference between Blue
You are now part of the Blue Shield of Califor-
                                                           Shield of California's payment (as described in
nia team along with Physicians, Hospitals, and
                                                           this Evidence of Coverage and Disclosure Form
other healthcare professionals working together
                                                           booklet) and the billed amount. Non-Preferred
toward a common goal — quality medical care
                                                           Providers have not agreed to accept Blue Shield
at reasonable costs.
                                                           of California's payment determination as pay-
To take full advantage of your Blue Shield of              ment-in-full. In addition, what Blue Shield of
California Preferred Plan, and avoid unneces-              California will pay for covered Services per-
sary liability, it is very important for you to            formed by a Non-Preferred Provider will usually
know how your plan works, what Blue Shield of              be considerably less than the amount billed.
California and its Preferred Providers are doing,          The additional cost to you could be substantial.
and what you, the Subscriber, will have to do.             It makes sense to select a Preferred Provider.




                                                    -10-
How to Make Your                                            Hospital, or other licensed healthcare provider.
Blue Shield of California                                   You should verify that the provider is a Pre-
                                                            ferred Provider, in case there have been any
Preferred Plan Work for You
                                                            changes since your Preferred Provider directory
First, read your Summary of Benefits and Evi-               was published.
dence of Coverage and Disclosure Form booklet
                                                            Your I.D. card has your Subscriber and group
carefully.
                                                            numbers on it. Be sure to include these numbers
Your booklet tells you which Services are cov-              on all claims you submit to Blue Shield of Cali-
ered by your health plan and which are ex-                  fornia.
cluded. It also spells out your responsibility for
any copayments and deductibles. These are im-               YOU MAY NEVER HAVE TO FILL OUT A
portant facts for your health care budget.                  CLAIM FORM...
                                                            Hospitals and Blue Shield of California Pre-
HOW TO RECEIVE SERVICES                                     ferred Providers usually bill Blue Shield of Cali-
Remember, it is to your advantage to use Blue               fornia directly.
Shield of California Preferred Providers for                ...But If You Do Need to Fill Out a Claim —
Services covered by your plan. When you use a               It's Easy.
Non-Preferred Provider, the Blue Shield of Cali-
fornia payment may be substantially less than               Send a copy of your itemized bill, along with a
the Billed Charge. (The exception to this is the            completed Blue Shield of California Sub-
use of Non-Preferred Hospitals for Emergency                scriber's Statement of Claim form to the Blue
Services. Further details are contained else-               Shield of California service center listed on the
where in the Evidence of Coverage and Disclo-               last page of this booklet.
sure Form booklet.) You will be responsible for
that portion of the Non-Preferred Provider's bill           You may call Blue Shield of California Cus-
over and above the amount Blue Shield of Cali-              tomer Service at the number listed on the last
fornia pays. Directories of the Preferred Pro-              page of this booklet to ask for forms. If neces-
viders in your immediate area have been pro-                sary, you may use a photocopy of the Blue
vided to you. Extra copies are available from               Shield of California claim form.
Blue Shield of California. If you do not have
                                                            Be sure to send in a claim for all covered Serv-
the copies you need, you should call Blue Shield
                                                            ices even if you have not yet met your Calendar
of California at the number listed on the last
                                                            Year deductible. Blue Shield of California will
page of this booklet.
                                                            keep track of the deductible for you. Blue
Members who reasonably believe that they have               Shield of California uses an Explanation of
an emergency medical condition which requires               Benefits to describe how your claim was proc-
an emergency response are encouraged to ap-                 essed and to inform you of your financial re-
propriately use the “911” emergency response                sponsibility.
system where available.
                                                            Requests for payment from any source must be
                                                            submitted to Blue Shield within 1 year after the
YOUR BLUE SHIELD OF CALIFORNIA I.D.                         month Services were provided. Blue Shield will
CARD IS YOUR PASSPORT TO SERVICE                            notify you of its determination within 30 days
When you need health care, present your Blue                after receipt of the claim.
Shield of California I.D. card to your Physician,




                                                     -11-
DEFINITIONS                                                fied orthotists, prosthetists and prosthetist-
                                                           orthotists.
Whenever any of the following terms are capi-
talized in this booklet, they will have the mean-          Billed Charges — the amount actually charged
ing stated below.                                          for covered Services except the amount which
                                                           exceeds that normally charged other patients for
Accidental Injury — definite trauma resulting              the same Service.
from a sudden, unexpected and unplanned
event, occurring by chance, caused by an inde-             Calendar Year — a period beginning on Janu-
pendent, external source.                                  ary 1 of any year and terminating on January 1
                                                           of the following year.
Activities of Daily Living (ADL) — the self-
care and mobility skills required for independ-            Chronic Care — care (different from Acute
ence in normal everyday living. This does not              Care) furnished to treat an illness, injury or con-
include recreational or sports activities.                 dition, which does not require hospitalization
                                                           (although confinement in a lesser facility may
Acute Care — care rendered in the course of                be appropriate), which may be expected to be of
treating an illness, injury or condition marked            long duration without any reasonably predict-
by a sudden onset or change of status requiring            able date of termination, and which may be
prompt attention, which may include hospitali-             marked by recurrences requiring continuous or
zation, but which is of limited duration and               periodic care as necessary.
which is not expected to last indefinitely.
                                                           Close Relative — the spouse, children, broth-
Allowable Amount — the Blue Shield of Cali-                ers, sisters or parents of a covered Person.
fornia Allowance (as defined below) for the
Service (or Services) rendered, or the provider's          Cosmetic Surgery — surgery that is performed
Billed Charge, whichever is less. The Blue                 to alter or reshape normal structures of the body
Shield of California Allowance is:                         to improve appearance.

1. the amount Blue Shield of California has                Creditable Coverage —
   determined is an appropriate payment for the            1. Any individual or group policy, contract or
   Service(s) rendered in the provider's geo-                 program, that is written or administered by a
   graphic area, based upon such factors as                   disability insurer, health care service plan,
   Blue Shield's evaluation of the value of the               fraternal benefits society, self-insured em-
   Service(s) relative to the value of other                  ployer plan, or any other entity, in this state
   Services, market considerations, and pro-                  or elsewhere, and that arranges or provides
   vider charge patterns; or                                  medical, hospital, and surgical coverage not
2. such other amount as the provider and Blue                 designed to supplement other private or
   Shield of California have agreed will be ac-               governmental plans. The term includes
   cepted as payment for the Service(s) ren-                  continuation or conversion coverage but
   dered; or                                                  does not include accident only, credit, cov-
                                                              erage for onsite medical clinics, disability
3. if an amount is not determined as described                income, Medicare supplement, long-term
   in either 1. or 2. above, the amount Blue                  care, dental, vision, coverage issued as a
   Shield of California determines is appropri-               supplement to liability insurance, insurance
   ate considering the particular circumstances               arising out of a workers' compensation or
   and the Services rendered.                                 similar law, automobile medical payment in-
                                                              surance, or insurance under which benefits
Alternate Care Services Providers — Home                      are payable with or without regard to fault
Medical Equipment suppliers, individual certi-                and that is statutorily required to be con-

                                                    -12-
   tained in any liability insurance policy or                 upon the Subscriber for support and mainte-
   equivalent self-insurance.                                  nance, or is dependent upon the Subscriber
                                                               for medical support by reason of a court or-
2. Title XVIII of the Social Security Act, e.g.,               der;
   Medicare.
                                                            and who has been enrolled and accepted by Blue
3. The Medicaid/Medi-Cal program pursuant                   Shield of California as a Dependent and has
   to Title XIX of the Social Security Act.                 maintained membership under the terms of the
                                                            contract.
4. Any other publicly sponsored or funded
   program of medical care.                                 3. If coverage for a Dependent child would be
                                                               terminated because of the attainment of age
Custodial or Maintenance Care — care fur-
                                                               19 (or age 25, if Dependent has been a full-
nished in the home primarily for supervisory
                                                               time student), and the Dependent child is
care or supportive services, or in a facility pri-
                                                               Totally Disabled (Physically Handicapped
marily to provide room and board (which may
                                                               or Mentally Retarded), benefits for such De-
or may not include nursing care, training in per-
                                                               pendent will be continued upon the follow-
sonal hygiene and other forms of self care
                                                               ing conditions:
and/or supervisory care by a Physician) or care
furnished to a Person who is mentally or physi-                a. the child must be chiefly dependent upon
cally disabled, and                                               the Subscriber for support and mainte-
                                                                  nance;
1. who is not under specific medical, surgical
   or psychiatric treatment to reduce the dis-                 b. the Subscriber submits to Blue Shield a
   ability to the extent necessary to enable the                  Physician's written certification of Total
   patient to live outside an institution provid-                 Disability within 31 days from the date
   ing care; or                                                   of the Employer's or Blue Shield's re-
                                                                  quest; and
2. when, despite medical, surgical or psychiat-
   ric treatment, there is no reasonable likeli-               c. thereafter, certification of continuing
   hood that the disability will be so reduced.                   disability and dependency from a Physi-
                                                                  cian is submitted to Blue Shield on the
Dependent —
                                                                  following schedule:
1. a Subscriber's legally married spouse who is
                                                                   (1) within 6 months after the month
   not covered for benefits as a Subscriber, and
                                                                       when the Dependent would other-
   is not legally separated from the Subscriber;
                                                                       wise have been terminated; and
   or
                                                                   (2) annually thereafter on the same
2. a Subscriber's unmarried child (including
                                                                       month when certification was
   any stepchild or child placed for adoption)
                                                                       made in accordance with item (1)
   who is: (a) less than 19 years of age; or (b)
                                                                       above. In no event will coverage
   less than 25 years of age, if a full-time stu-
                                                                       be continued beyond the date when
   dent and proof of student status is submitted
                                                                       the Dependent child becomes in-
   to and received by Blue Shield. Full-time
                                                                       eligible for coverage under this
   student means a Dependent must be en-
                                                                       plan for any reason other than at-
   rolled in a college, university, vocational or
                                                                       tained age.
   technical school for a minimum of 8 units as
   an undergraduate, or 6 units as a graduate               Doctor of Medicine — a licensed Medical
   student; and (c) not covered for benefits as a           Doctor (M.D.) or Doctor of Osteopathic Medi-
   Subscriber; and (d) primarily dependent                  cine (D.O.).

                                                     -13-
Domiciliary Care — care provided in a Hospi-                   by any State government agency, prior to use
tal or other licensed facility because care in the             and where such approval has not been granted at
patient's home is not available or is unsuitable.              the time the services or supplies were rendered,
                                                               shall be considered experimental or investiga-
Emergency Services — Services provided for                     tional in nature. Services or supplies which
an unexpected medical condition, including a                   themselves are not approved or recognized in
psychiatric emergency medical condition, mani-                 accordance with accepted professional medical
festing itself by acute symptoms of sufficient                 standards, but nevertheless are authorized by
severity (including severe pain) such that the                 law or by a government agency for use in test-
absence of immediate medical attention could                   ing, trials, or other studies on human patients,
reasonably be expected to result in any of the                 shall be considered experimental or investiga-
following:                                                     tional in nature.
1. placing the patient's health in serious jeop-               Family — the Subscriber and all enrolled De-
   ardy;                                                       pendents.
2. serious impairment to bodily functions;                     Group Health Service Contract (Contract) —
                                                               the contract issued by the Plan to the contrac-
3. serious dysfunction of any bodily organ or
                                                               tholder that establishes the services that Sub-
   part.
                                                               scribers and Dependents are entitled to receive
Employee — an individual who meets the eli-                    from the Plan.
gibility requirements set forth in the Group
                                                               Home Medical Equipment — equipment de-
Health Service Contract between Blue Shield of
                                                               signed for repeated use which is medically nec-
California and your employer.
                                                               essary to treat an illness or injury, to improve
Employer — any person, firm, proprietary or                    the functioning of a malformed body member,
non-profit corporation, partnership, public                    or to prevent further deterioration of the pa-
agency or association that has at least 2 employ-              tient's medical condition.       Home Medical
ees and that is actively engaged in business or                Equipment includes items such as wheelchairs,
service, in which a bona fide employer-                        hospital beds, respirators, and other items that
employee relationship exists, in which the ma-                 Blue Shield of California determines are Home
jority of employees were employed within this                  Medical Equipment.
state, and which was not formed primarily for
                                                               Hospice or Hospice Agency — an entity which
purposes of buying health care coverage or in-
                                                               provides Hospice Services to Terminally Ill Per-
surance.
                                                               sons and holds a license, currently in effect as a
Enrollment Date — the first day of coverage,                   Hospice pursuant to Health and Safety Code
or if there is a waiting period, the first day of the          Section 1747, or a home health agency licensed
waiting period (typically, date of hire).                      pursuant to Health and Safety Code Sections
                                                               1726 and 1747.1 which has Medicare certifica-
Experimental or Investigational in Nature —                    tion.
any treatment, therapy, procedure, drug or drug
usage, facility or facility usage, equipment or                Hospital —
equipment usage, device or device usage, or
                                                               1. a licensed institution primarily engaged in
supplies which are not recognized in accordance
                                                                  providing, for compensation from patients,
with generally accepted professional medical
                                                                  medical, diagnostic and surgical facilities for
standards as being safe and effective for use in
                                                                  care and treatment of sick and injured per-
the treatment of the illness, injury, or condition
                                                                  sons on an Inpatient basis, under the super-
at issue. Services which require approval by the
                                                                  vision of an organized medical staff, and
Federal government or any agency thereof, or
                                                                  which provides 24 hour a day nursing serv-

                                                        -14-
   ice by registered nurses. A facility which is                 a. The Employee or Dependent was cov-
   principally a rest home or nursing home or                       ered under another employer health
   home for the aged is not included.                               benefit plan at the time he or she was of-
                                                                    fered enrollment under this plan; and
2. a psychiatric Hospital accredited by the Joint
   Commission on Accreditation of Healthcare                     b. The Employee or Dependent certified, at
   Organizations.                                                   the time of the initial enrollment, that
                                                                    coverage under another employer health
3. a psychiatric healthcare facility as defined in                  benefit plan was the reason for declining
   Section 1250.2 of the Health and Safety                          enrollment, provided that, if he or she
   Code; or                                                         was covered under another employer
                                                                    health plan, he or she was given the op-
4. a facility operated primarily for the treat-
                                                                    portunity to make the certification re-
   ment of alcoholism and accredited by the
                                                                    quired and was notified that failure to do
   Joint Commission on Accreditation of
                                                                    so could result in later treatment as a
   Healthcare Organizations.
                                                                    Late Enrollee; and
Incurred — a charge will be considered to be
                                                                 c. The Employee or Dependent has lost or
“Incurred” on the date the particular service or
                                                                    will lose coverage under another em-
supply which gives rise to it is provided or ob-
                                                                    ployer health benefit plan as a result of
tained.
                                                                    termination of his or her employment or
Infertility — either (1) the presence of a dem-                     of the individual through whom he or
onstrated bodily malfunction recognized by a                        she was covered as a dependent, change
licensed Doctor of Medicine as a cause of infer-                    in his or her employment status or of the
tility, or (2) because of a demonstrated bodily                     individual through whom he or she was
malfunction, the inability to conceive a preg-                      covered as a dependent, termination of
nancy or to carry a pregnancy to a live birth af-                   the other plan's coverage, exhaustion of
ter a year or more of regular sexual relations                      COBRA continuation coverage, cessa-
without contraception.                                              tion of an employer's contribution to-
                                                                    ward his or her coverage, death of the
Inpatient — an individual who has been ad-                          individual through whom he or she was
mitted to a Hospital as a registered bed patient                    covered as a dependent, or legal separa-
and is receiving Services under the direction of                    tion or divorce; and
a Physician.
                                                                 d. The Employee or Dependent requests
Late Enrollee — an eligible Employee or De-                         enrollment within 31 days after termina-
pendent who has declined enrollment in this                         tion of coverage or employer contribu-
plan at the time of the initial enrollment period,                  tion toward coverage provided under an-
and who subsequently requests enrollment in                         other employer health benefit plan; or
this plan; provided that the initial enrollment pe-
riod shall be a period of at least 30 days. How-              2. The employer offers multiple health benefit
ever, an eligible Employee or Dependent shall                    plans and the eligible Employee elects this
not be considered a Late Enrollee if any of the                  plan during an open enrollment period; or
following paragraphs (1.), (2.), (3.), (4.), (5.) or
                                                              3. A court has ordered that coverage be pro-
(6.) is applicable:
                                                                 vided for a spouse or minor child under a
1. The eligible Employee or Dependent meets                      covered Employee’s health benefit plan.
   all of the following requirements of (a.),                    The health plan shall enroll a Dependent
   (b.), (c.) and (d.):                                          child within 31 days of presentation of a



                                                       -15-
   court order by the district attorney, or upon             control and care for their own welfare, or for the
   presentation of a court order or request by a             welfare of others, or for the welfare of the
   custodial party, as described in Section                  community.
   3751.5 of the Family Code; or
                                                             Non-Participating Home Health Care and
4. For eligible Employees or Dependents who                  Home Infusion agency — an agency which has
   fail to elect coverage in this plan during their          not contracted with Blue Shield and whose
   initial enrollment period, the plan cannot                services are not covered unless prior authorized
   produce a written statement from the em-                  by Blue Shield.
   ployer stating that prior to declining cover-
   age, the Employee or Dependent, or the in-                Non-Participating/Non-Preferred Providers
   dividual through whom he or she was                       — any provider who has not contracted with
   eligible to be covered as a dependent, was                Blue Shield to accept Blue Shield's payment,
   provided with and signed acknowledgment                   plus any applicable deductible, copayment or
   of a Refusal of Personal Coverage form                    amounts in excess of specified benefit maxi-
   specifying that failure to elect coverage                 mums, as payment-in-full for covered Services.
   during the initial enrollment period permits              Certain services of this Plan are not covered or
   the plan to impose, at the time of his or her             benefits are reduced if the service is provided by
   later decision to elect coverage, an exclusion            a Non-Participating/Non-Preferred Provider.
   from coverage for a period of 12 months, as
                                                             Open Enrollment Period — that period of time
   well as a 6 month Pre-existing Condition
                                                             set forth in the contract during which eligible
   exclusion, unless he or she meets the criteria
                                                             employees and their dependents may transfer
   specified in paragraphs (1.), (2.) or (3.)
                                                             from another health benefit plan sponsored by
   above; or
                                                             the employer to the Preferred Plan.
5. For eligible Dependents who have lost or
                                                             Orthosis — an orthopedic appliance or appara-
   will lose their no share-of-cost Medi-Cal
                                                             tus used to support, align, prevent or correct de-
   coverage and who request enrollment within
                                                             formities or to improve the function of movable
   31 days after notification of this loss of cov-
                                                             body parts.
   erage.
                                                             Other Providers —
6. For eligible Employees who decline cover-
   age during the initial enrollment period and              1. Independent Practitioners — licensed voca-
   subsequently acquire Dependents through                      tional nurses; licensed practical nurses; reg-
   marriage, birth, or placement for adoption,                  istered nurses; licensed psychiatric nurses;
   and who enroll for coverage for themselves                   certified nurse anesthetists; certified nurse
   and their Dependents within 31 days from                     midwives; licensed occupational therapists;
   the date of marriage, birth, or placement for                certificated acupuncturists; inhalation and
   adoption.                                                    enterostomal therapists; licensed speech
                                                                therapists or pathologists; dental technicians;
Mental Health Services — see definition of                      and lab technicians.
Psychiatric Care.
                                                             2. Healthcare Organizations — nurses registry;
Mentally Retarded (or Mental Retardation)                       licensed mental health, freestanding public
— only those Persons, not psychotic, who are so
                                                                health, rehabilitation, hemodialysis and Out-
Mentally Retarded from infancy or before
                                                                patient clinics not MD owned; portable X-
reaching maturity that they are incapable of
                                                                ray companies; lay-owned independent labo-
managing themselves and their affairs inde-
                                                                ratories; blood banks; speech and hearing
pendently, with ordinary prudence, or of being
                                                                centers; dental laboratories; dental supply
taught to do so, and who require supervision,
                                                                companies; nursing homes; ambulance com-

                                                      -16-
   panies; Easter Seal Society; American Can-               Participating Provider — a Physician, a Hos-
   cer Society and Catholic Charities.                      pital, an Ambulatory Surgery Center, an Alter-
                                                            nate Care Services Provider, or a Home Health
Outpatient — an individual receiving Services               Care and Home Infusion Agency that has con-
but not as an Inpatient.                                    tracted with Blue Shield of California to furnish
                                                            Services and to accept Blue Shield of Califor-
Outpatient Facility — a licensed facility, not a
                                                            nia's payment, plus applicable deductibles and
Physician's office or Hospital, that provides
                                                            copayments, as payment in full for covered
medical and/or surgical Services on an Outpa-
                                                            Services, except as provided under the Payment
tient basis.
                                                            and Subscriber copayment provision in this
Participating Ambulatory Surgery Center —                   booklet. Certain services of this Plan are not
a licensed Ambulatory Surgery facility which                covered or benefits are reduced if the service is
has contracted with Blue Shield to provide sur-             provided by a Participating Provider that is not a
gical Services on an Outpatient basis and accept            Preferred Provider.
reimbursement at negotiated rates.
                                                            NOTE: this definition does not apply to Hos-
Participating Home Health Care and Home                     pice Program Services. For Participat-
Infusion agency — an agency which has con-                  ing/Preferred Providers for Hospice Program
tracted with Blue Shield to furnish Services and            Services, see the Participating Hospice or Par-
accept reimbursement at negotiated rates, and               ticipating Hospice Agency definitions above.
which has been designated as a Participating
                                                            Person — either a Subscriber or Dependent.
Home Health Care and Home Infusion agency
by Blue Shield. (See Non-Participating Home                 Physical Handicap — a physical or mental im-
Health Care and Home Infusion agency defini-                pairment that results in anatomical, physiologi-
tion above.)                                                cal, or psychological abnormalities which are
                                                            demonstrable by medically acceptable clinical
Participating Hospice or Participating Hos-
                                                            or laboratory diagnostic techniques and which
pice Agency — an entity which: 1) provides
                                                            are expected to last for a continuous period of
Hospice Services to Terminally Ill Persons and
                                                            time not less than 12 months in duration.
holds a license, currently in effect, as a Hospice
pursuant to Health and Safety Code Section                  Physical Medicine — Services including but
1747, or a home health agency licensed pursuant             not limited to physical medicine evaluations and
to Health and Safety Code Sections 1726 and                 management, office visits, patient training, and
1747.1 which has Medicare certification and 2)              treatment utilizing physical agents, such as ul-
has either contracted with Blue Shield of Cali-             trasound, heat and massage, rendered by a
fornia or has received prior approval from Blue             Doctor of Medicine, registered physical thera-
Shield of California to provide Hospice Service             pist or certified occupational therapist to im-
benefits pursuant to the California Health and              prove a patient's musculoskeletal, neuromuscu-
Safety Code Section 1368.2.                                 lar and respiratory systems.
Participating Physician — a Physician or a                  Physician — a licensed Doctor of Medicine,
Physician Member that has contracted with Blue              clinical psychologist, research psychoanalyst,
Shield to furnish Services and to accept Blue               dentist, licensed clinical social worker, optome-
Shield's payment, plus applicable deductibles               trist, chiropractor, podiatrist, audiologist, regis-
and copayments, as payment-in-full for covered              tered physical therapist, or licensed marriage
Services, except as provided under the Payment              and family therapist.
and Subscriber copayment provision in this
booklet.



                                                     -17-
Physician Member — a Doctor of Medicine                    modalities and are provided for as long as con-
who has enrolled with Blue Shield as a Physi-              tinued treatment is Medically Necessary pursu-
cian Member.                                               ant to the treatment plan.
Pre-existing Condition — an illness, injury or             Services — includes medically necessary
condition (including Total Disability) which               healthcare Services and medically necessary
existed during the 6 months prior to the enroll-           supplies furnished incident to those Services.
ment date of coverage if, during that time, any
medical advice, diagnosis, care or treatment was           Skilled Nursing Facility — a facility with a
recommended or received from a licensed health             valid license issued by the California Depart-
practitioner.                                              ment of Health Services as a Skilled Nursing
                                                           Facility or any similar institution licensed under
Preferred Hospital — a Hospital under con-                 the laws of any other state, territory, or foreign
tract to Blue Shield which has agreed to furnish           country.
Services and accept reimbursement at negoti-
ated rates, and which has been designated as a             Special Food Products — a food product
Preferred Hospital by Blue Shield.                         which is both of the following:

Preferred Provider — a Physician Member, a                 1. Prescribed by a Physician or nurse practitio-
Preferred Hospital, or a Participating Provider.              ner for the treatment of phenylketonuria
                                                              (PKU) and is consistent with the recommen-
Prosthesis — an artificial part, appliance or de-             dations and best practices of qualified health
vice used to replace a missing part of the body.              professionals with expertise germane to, and
                                                              experience in the treatment and care of,
Psychiatric Care (Mental Health Services) —                   phenylketonuria (PKU). It does not include
psychoanalysis, psychotherapy, counseling,                    a food that is naturally low in protein, but
medical management, or other Services pro-                    may include a food product that is specially
vided by a psychiatrist, psychologist, licensed               formulated to have less than one gram of
clinical social worker, or licensed marriage and              protein per serving;
family therapist, for diagnosis or treatment of a
mental or emotional disorder or the mental or              2. Used in place of normal food products, such
emotional problems associated with an illness,                as grocery store foods, used by the general
injury, or any other condition.                               population.
Reconstructive Surgery — surgery to correct                Speech Therapy — treatment, under the direc-
or repair abnormal structures of the body caused           tion of a Doctor of Medicine and provided by a
by congenital defects, developmental abnor-                licensed speech pathologist or speech therapist,
malities, trauma, infection, tumors or disease to          to improve or retrain a patient's vocal skills
do either of the following: 1) to improve func-            which have been impaired by illness or injury.
tion, or 2) to create a normal appearance to the
extent possible.                                           Subacute Care — skilled nursing or skilled re-
                                                           habilitative care provided in a hospital or skilled
Rehabilitation or Rehabilitative Care — care               nursing facility to patients who require skilled
furnished to an Inpatient primarily to restore an          care such as nursing services, physical, occupa-
individual's ability to function as normally as            tional or speech therapy, a coordinated program
possible after a disabling illness or injury. Re-          of multiple therapies or who have medical needs
habilitation or Rehabilitative Care services con-          that require daily Registered Nurse monitoring.
sist of the combined use of medical, social, edu-          A facility which is primarily a rest home, con-
cational, occupational/vocational treatment                valescent facility or home for the aged is not in-
                                                           cluded.


                                                    -18-
Subscriber — an individual who satisfies the                You and your Dependents will not be consid-
eligibility requirements of an Employee, who                ered to be Late Enrollees if either you or your
has been enrolled and accepted by Blue Shield               Dependents lose coverage under another em-
of California as a Subscriber, and has main-                ployer health plan and you apply for coverage
tained Blue Shield of California coverage under             under this Plan within 31 days of the date of loss
the group contract.                                         of coverage. You will be required to furnish
                                                            Blue Shield written proof of the loss of cover-
Total Disability (or Totally Disabled) —                    age.
1. in the case of an Employee or Person other-              Newborn infants of the Subscriber will be eligi-
   wise eligible for coverage as an Employee, a             ble immediately after birth for the first 31 days.
   disability which prevents the individual                 Children placed for adoption will be eligible
   from working with reasonable continuity in               immediately upon the date the Subscriber or
   the individual's customary employment or in              spouse has the right to control the child's health
   any other employment in which the individ-               care. Evidence of such control includes a health
   ual reasonably might be expected to engage,              facility minor release report, a medical authori-
   in view of the individual's station in life and          zation form or a relinquishment form. In order
   physical and mental capacity;                            to have coverage continue beyond the first 31
                                                            days without lapse, a written application must
2. in the case of a Dependent, a disability
                                                            be submitted to and received by Blue Shield
   which prevents the individual from engaging
                                                            prior to 31 days from the date of birth or place-
   with normal or reasonable continuity in the
                                                            ment for adoption of such Dependent.
   individual's customary activities or in those
   in which the individual otherwise reasonably             You may add newly acquired Dependents and
   might be expected to engage, in view of the              yourself to the plan by submitting a written ap-
   individual's station in life and physical and            plication on forms furnished by Blue Shield of
   mental capacity.                                         California within 31 days from the date of ac-
                                                            quisition of the Dependent:
ELIGIBILITY                                                 1. to continue coverage of a newborn or child
If you are an Employee as defined, you are eli-                placed for adoption;
gible for coverage as a Subscriber the day fol-             2. to add a Spouse after marriage;
lowing the date you complete the waiting period
established by your Employer. Your spouse and               3. to add yourself and Spouse following birth
all your dependent children are eligible at the                of a newborn or placement of a child for
same time.                                                     adoption;
When you decline coverage for yourself or your              4. to add yourself and Spouse after marriage;
Dependents during the initial enrollment period
and later request enrollment, you and your De-              5. to add yourself and your newborn or child
pendents will be considered to be Late Enrol-                  placed for adoption, following birth or
lees. When Late Enrollees decline enrollment                   placement for adoption.
during the initial enrollment period they will be
                                                            Coverage is never automatic; an application is
eligible the earlier of 12 months from the date of
                                                            always required.
the request for enrollment or at the Employer’s
next open enrollment period and shall be subject            If a husband and wife are both eligible to be
to a 6-month Pre-Existing Condition exclusion.              Subscribers, children may be eligible and may
Blue Shield will not consider applications for              be enrolled as a Dependent of either parent, but
earlier effective dates.                                    not both.


                                                     -19-
Enrolled dependent children who would nor-                   Pre-Existing Condition exclusion. Blue Shield
mally lose their eligibility under this plan solely          will not consider applications for earlier effec-
because of age, but who are Physically Handi-                tive dates.
capped or Mentally Retarded, may have their
eligibility extended under the following condi-              If you declined coverage for yourself and your
tions: (1) the child must be chiefly dependent               Dependents during the initial enrollment period
upon the Employee for support and mainte-                    because you were covered under another em-
nance, and (2) the Employee must submit a                    ployer health plan, and subsequently lost cover-
Physician's written certification of Mental Re-              age under that plan, you will not be considered a
tardation or Physical Handicap within 31 days                Late Enrollee. Coverage for you and your De-
of the request for information by the Employer               pendents under this Plan becomes effective on
or by Blue Shield. Proof of continuing disabil-              the date of loss of coverage, provided you re-
ity and dependency must be submitted by the                  quest enrollment in this Plan within 31 days of
Employee 6 months later and annually thereaf-                the date of loss of coverage. You will be re-
ter.                                                         quired to furnish Blue Shield of California
                                                             written evidence of loss of coverage.
Subject to the requirements described under the
Continuation of Group Coverage provision in                  If you declined coverage for yourself and your
this booklet, if applicable, an Employee and his             Dependents during the initial enrollment period
or her Dependents will be eligible to continue               because your Dependents were covered under
group coverage under this plan when coverage                 another employer health plan, and your De-
would otherwise terminate.                                   pendents have lost that coverage, you will not
                                                             be considered a Late Enrollee. You and your
                                                             Dependents may apply for enrollment within 31
EFFECTIVE DATE OF COVERAGE                                   days from the date of loss of coverage. Cover-
                                                             age under this plan will be effective on the date
Your coverage will become effective at 12:01                 of loss of coverage. You will be required to
a.m. Pacific Time on the eligibility date estab-             furnish Blue Shield of California written evi-
lished by your Employer. You become eligible                 dence of loss of coverage.
when you submit a written application on the
form furnished by Blue Shield within 31 days of              If you declined enrollment during the initial en-
that date. If you enroll during the initial enroll-          rollment period and subsequently acquire De-
ment period, you will become eligible on your                pendents as a result of marriage, birth, or
eligibility date.                                            placement for adoption, you may request en-
                                                             rollment for yourself and your Dependents
If, during the initial enrollment period, you have           within 31 days from the date of marriage, birth,
included your eligible Dependents on your ap-                or placement for adoption. The effective date of
plication to Blue Shield, their coverage will be             enrollment for both you and your Dependents
effective on the same date as yours. If applica-             will depend on how you acquire your Depend-
tion is made for Dependent coverage within 31                ent(s):
days after you become eligible, their effective
date of coverage will be the same as yours.                  1. For marriage, the effective date will be the
                                                                first day of the first month following receipt
If you or your Dependent is a Late Enrollee,                    of your request for enrollment;
your coverage will become effective the earlier
of 12 months from the date of request for en-                2. For birth, the effective date will be the date
rollment or at the Employer’s next open enroll-                 of birth;
ment period and shall be subject to a 6-month
                                                             3. For a child placed for adoption, the effective
                                                                date will be the date the Subscriber or


                                                      -20-
   Spouse has the right to control the child’s              of request for reinstatement or at the Employer’s
   health care.                                             next open enrollment period.
Once each calendar year, your employer may                  If this plan provides benefits within 60 days of
designate a time period as an annual open en-               the date of discontinuance of the previous group
rollment period. During that time period, you               health plan that was in effect with your Em-
and your dependents may transfer from another               ployer;
health plan sponsored by your employer to the
Preferred Plan. A completed enrollment form                 1. you and all your Dependents who were val-
must be forwarded to Blue Shield within the                    idly covered under the previous group health
open enrollment period. Enrollment becomes                     plan on the date of discontinuance, will be
effective on the anniversary date of this Plan                 eligible under this plan except that,
following the annual open enrollment period.
                                                            2. if you or your Dependents were enrolled in
Any individual who becomes eligible at a time                  the previous group health plan for less than
other than during the annual open enrollment                   6 months and were Totally Disabled on the
(e.g., newborn, child placed for adoption, new                 date of discontinuance of the previous group
spouse, newly hired or newly transferred em-                   health plan and were entitled to an extension
ployees) must complete an enrollment form                      of benefits under Section 1399.62 of the
within 31 days of becoming eligible.                           California Health and Safety Code or Sec-
                                                               tion 10128.2 of the California Insurance
Coverage for a newborn child will become ef-                   Code, you or your Dependents will not be
fective on the date of birth. Coverage for a                   entitled to any benefits under this plan for
child placed for adoption is effective the date                Services or expenses directly related to any
the Subscriber or spouse has the right to control              condition which caused such Total Disabil-
the child's health care. Evidence of such control              ity for a period not to exceed 6 months. Blue
includes a health facility minor release report, a             Shield will credit the time you or your De-
medical authorization form or a relinquishment                 pendents were covered under the prior
form. In order to have coverage continue be-                   Creditable Coverage toward this plan’s Pre-
yond the first 31 days without lapse, a written                existing Condition exclusion.
application must be submitted to and received
by Blue Shield prior to 31 days from the date of
birth or placement for adoption of such Depend-             RENEWAL OF GROUP HEALTH
ent. A dependent spouse becomes eligible on                 SERVICE CONTRACT
the date of marriage.
                                                            Blue Shield of California will offer to renew the
If a court has ordered that you provide coverage            Group Health Service Contract except in the
for your spouse or Dependent child, under your              following instances:
health benefit plan, their coverage will become
effective within 31 days of presentation of a               1. non-payment of dues;
court order by the district attorney, or upon               2. fraud, misrepresentations or omissions;
presentation of a court order or request by a
custodial party, as described in Section 3751.5             3. failure to comply with Blue Shield's appli-
of the Family Code.                                            cable eligibility, participation or contribu-
                                                               tion rules;
If you or your Dependents voluntarily discon-
tinued coverage under this plan and later request           4. termination of plan type by Blue Shield;
reinstatement, you or your Dependents will be
covered the earlier of 12 months from the date              5. Employer moves out of the service area;



                                                     -21-
6. association membership ceases.                             c. not furnished primarily for the conven-
                                                                 ience of the patient, the attending Physi-
All groups will renew subject to the above.                      cian or other provider; and
                                                              d. furnished at the most appropriate level
PREPAYMENT FEE                                                   which can be provided safely and effec-
1. The monthly dues for you and your Depend-                     tively to the patient.
   ents are indicated in your employer’s group             2. Hospital Inpatient Services which are medi-
   contract. The initial dues are payable on the              cally necessary include only those Services
   effective date of this health plan, and subse-             which satisfy the above requirements, re-
   quent dues are payable on the same date of                 quire the acute bed-patient (overnight) set-
   each succeeding month. Dues are payable in                 ting, and which could not have been pro-
   full on each transmittal date and must be                  vided in the Physician's office, the
   made for all Subscribers and Dependents.                   Outpatient department of a Hospital, or in
2. All dues required for coverage for you and                 another lesser facility without adversely af-
   your Dependents will be handled through                    fecting the patient's condition or the quality
   your Employer, and must be paid to Blue                    of medical care rendered. Inpatient Services
   Shield of California. Payment of dues will                 not medically necessary include hospitaliza-
   continue the benefits of this health plan up               tion:
   to the date immediately before the next                    a. for diagnostic studies that could have
   transmittal date, but not after.                              been provided on an Outpatient basis;
                                                              b. for medical observation or evaluation;
PLAN CHANGES
                                                              c. for personal comfort;
The benefits of this plan are subject to change
following at least 30 days' written notice by                 d. in a pain management center to treat or
Blue Shield. Benefits for Services or supplies                   cure chronic pain; and
furnished on or after the effective date of any               e. for Inpatient Rehabilitation or Rehabili-
change in benefits will be provided based on the                 tative Care that can be provided on an
change.                                                          Outpatient basis.

                                                           3. Blue Shield of California reserves the right
MEDICAL NECESSITY                                             to review all claims to determine whether
                                                              Services are medically necessary, and may
The benefits of this plan are provided only for
                                                              use the services of Physician consultants,
Services which are medically necessary.
                                                              peer review committees of professional so-
1. Services which are medically necessary in-                 cieties or Hospitals, and other consultants.
   clude only those which have been estab-
   lished as safe and effective, are furnished             UTILIZATION REVIEW
   under generally accepted professional stan-
   dards to treat illness, injury or medical con-          State law requires that health plans disclose to
   dition, and which, as determined by Blue                Subscribers and health plan providers the proc-
   Shield, are:                                            ess used to authorize or deny health care serv-
   a. consistent with Blue Shield of California            ices under the plan.
      medical policy;                                      Blue Shield has completed documentation of
   b. consistent with the symptoms or diagno-              this process (“Utilization Review”), as required
      sis;

                                                    -22-
under Section 1363.5 of the California Health              Lifepath Advisers includes a nurseline (see
and Safety Code.                                           Principal Benefits & Coverages, the Preventive
                                                           Care Benefits section).
To request a copy of the document describing
this Utilization Review process, call the Cus-
tomer Service Department at the number listed              BLUE SHIELD ONLINE
in the back of this booklet.
                                                           Blue Shield’s Internet site is located at
                                                           http://www.mylifepath.com.    Members with
SECOND MEDICAL OPINION POLICY                              Internet access and a Web browser may view
                                                           and download healthcare information.
If you have a question about your diagnosis or
believe that additional information concerning
your condition would be helpful in determining             BENEFITS MANAGEMENT PROGRAM
the most appropriate plan of treatment, you may
make an appointment with another physician for             Blue Shield has established the Benefits Man-
a second medical opinion. Your attending phy-              agement Program to assist you, your Depend-
sician may also offer to refer you to another              ents or provider in identifying the most appro-
physician for a second opinion.                            priate and cost-effective course of treatment for
                                                           which benefits will be provided under this
Remember that the second opinion visit is sub-             health plan and for determining whether the
ject to all Plan contract benefit limitations and          services are medically necessary. However,
exclusions. Additionally, please see the section           you, your Dependents and provider make the fi-
on "Your Blue Shield of California Preferred               nal decision concerning treatment. The Benefits
Plan and How to Use It" regarding advantages               Management Program includes preservice re-
of selecting a Preferred Physician for these               view; prior authorization for certain Services;
services.                                                  preadmission review (except for emergency
                                                           admissions), emergency admission notification
                                                           (for emergency admissions), hospital inpatient
HEALTH EDUCATION AND                                       utilization review; discharge planning; and care
HEALTH PROMOTION SERVICES                                  management if determined to be applicable and
                                                           appropriate by Blue Shield. Certain portions
Health education and health promotion services             of the Benefits Management Program also
provided by Blue Shield’s Center for Health                contain Additional and Reduced Payment
Improvement offer a variety of wellness re-                requirements for either not contacting Blue
sources including, but not limited to: a member            Shield or not following Blue Shield’s recom-
newsletter and a prenatal health education pro-            mendations and may also result in non-
gram.                                                      payment if Blue Shield determines the service
                                                           was not a covered Service. Please read the
LIFEPATH ADVISERS                                          following sections thoroughly so you under-
                                                           stand your responsibilities in reference to the
Blue Shield of California's Lifepath Advisers              Benefits Management Program. Remember
provides Persons with no charge, confidential,             that all provisions of the Benefit Management
unlimited telephone support for information,               Program also apply to your Dependents.
consultations, and referrals for health issues.
Persons may obtain these services by calling               Blue Shield requires preservice review for
1-866-543-3728, a 24-hour, toll-free telephone             selected Inpatient and Outpatient Services,
number. There is no charge for these services.             supplies and Home Medical Equipment;
                                                           prior authorization for all home health care,



                                                    -23-
home infusion/ home injectable services, and                    plants originally provided for cosmetic
PKU related formulas and Special Food                           augmentation are not covered;
Products; prior authorization for admission
into an approved Hospice Program; prior                      3. Arthroscopic surgery of the temporoman-
authorization for certain radiology proce-                      dibular joint (TMJ).
dures; preadmission review for all Inpatient
                                                             Note: it is to your advantage to contact Blue
Hospital Services (except for Emergency
                                                             Shield for preservice review to determine
Services) and notification for Inpatient
                                                             whether services are medically necessary and
Emergency Services. In these situations, you
                                                             whether they are covered services under your
or your provider need to call Blue Shield as
                                                             plan.
described in the following sections. By ob-
taining preservice review or prior authorization
for certain Services or preadmission review                  PRIOR AUTHORIZATION
prior to receiving Services, you and your pro-
                                                             Before Services are provided, you or your pro-
vider will know: whether: (1) Blue Shield con-
                                                             vider can determine whether a Procedure or
siders the proposed treatment medically neces-
                                                             treatment program is covered and may also re-
sary, (2) if plan benefits will be provided for the
                                                             ceive a recommendation for an alternative
proposed treatment, and (3) if the proposed set-
                                                             Service.
ting is the most appropriate as determined by
Blue Shield. You and your provider are in-                   Blue Shield requires prior authorization for
formed about Services that could be performed                the following Services:
on an Outpatient basis in a Hospital or Outpa-
tient Facility.                                              1. Home      Health    Care,   Home    Infu-
                                                                sion/Injectable Care and PKU related for-
PRESERVICE REVIEW                                               mulas and Special Food Products.

Before Services are provided, you and your pro-                 Call 1-800-343-1691 for prior authorization
vider can learn whether a procedure or treatment                for these services.
program is covered by calling Blue Shield at                 Failure to receive Prior Authorization or to
1-800-343-1691.                                              follow the recommendations of Blue Shield
Examples of Services for which Blue Shield of                for Home Health Care and Home Infu-
California recommends that you or your pro-                  sion/Injectable Care services may result in
vider contact Blue Shield are:                               non-payment if the service is determined not
                                                             to be a covered Service.
1. Home Medical Equipment, such as motor-
   ized wheelchairs, insulin infusion pumps,                 Failure to receive Prior Authorization or to
   and CPAP (Continuous Positive Air Pres-                   follow the recommendations of Blue Shield
   sure) machines;                                           for covered, Medically Necessary enteral
                                                             formulas and Special Food Products for the
2. Surgery which may be considered to be                     treatment of phenylketonuria (PKU) will re-
   Cosmetic in nature rather than Reconstruc-                sult in a 50% reduction in the amount pay-
   tive (e.g., eyelid surgery, rhinoplasty or                able by Blue Shield after the calculation of
   breast reduction) and those Reconstructive                the deductible and any applicable copay-
   Surgeries which may result in only minimal                ments required by this plan. You will be re-
   improvement. Reconstructive Surgeries                     sponsible for the applicable deductibles
   which may result in only minimal improve-                 and/or copayments and the additional 50% of
   ment in function or appearance, Cosmetic                  the charges that are payable under this plan.
   Surgeries and reimplantation of breast im-                The additional 50% responsibility will not be


                                                      -24-
included in the calculation of the Subscriber’s           3. Admission into an approved Hospice Pro-
Maximum Calendar Year Copayment re-                          gram as specified under Hospice Program
sponsibility.                                                Services in the Covered Services section.
2. The following radiological procedures when                Call 1-800-343-1691 for information on re-
   performed in an outpatient setting on a non-              questing admission to a Hospice Program.
   emergency basis:
                                                          Failure to receive Prior Authorization for
   CT (Computerized Tomography) scans,                    hospice services or to follow the recommen-
   MRI’s (Magnetic Resonance Imaging),                    dations of Blue Shield will result in non-
   MRA’s (Magnetic Resonance Angiogra-                    payment of services by Blue Shield.
   phy), PET (Positron Emission Tomography)
   Scans, Bone Densitometry testing and any               4. Clinical Trial for Cancer.
   cardiac diagnostic procedure utilizing Nu-
                                                             Persons who have been accepted into an ap-
   clear Medicine.
                                                             proved clinical trial for cancer as defined
   Call 1-888-642-2583 for prior authorization               under the Covered Services section must
   for these services.                                       obtain prior authorization from Blue Shield
                                                             in order for the routine patient care delivered
Failure to receive prior authorization for                   in a clinical trial to be covered.
these services or to follow the recommenda-
tions of Blue Shield will result in reduced                  Call 1-800-343-1691 for prior authorization
payment amounts per procedure and non-                       for these services.
payment for procedures which are deter-
                                                          Failure to receive Prior Authorization for a
mined not to be covered services.
                                                          clinical trial for cancer will result in non-
♦ For covered services that are not author-               payment of services by Blue Shield.
  ized in advance, the amount payable will                NOTE: Blue Shield will render a decision on
  be reduced by 50% after the calculation                 all requests for pre-service review, prior
  of the deductible and any applicable                    authorization and pre-admission review
  copayments required by this plan. You                   within 5 business days from receipt of the re-
  will be responsible for the remaining 50%               quest. The treating provider will be notified
  and applicable deductible and/or copay-                 of the decision within 24 hours followed by
  ments. This additional 50% responsibility               written notice to the provider and Subscriber
  will not be included in the calculation of              within 2 business days of the decision. For
  the subscriber’s maximum calendar year                  urgent services in situations in which the rou-
  copayment responsibility;                               tine decision making process might seriously
♦ For services provided by a Non-Preferred                jeopardize the life or health of a Person or
  Provider, the subscriber will also be re-               when the Person is experiencing severe pain,
  sponsible for all charges in excess of the              Blue Shield will respond within 72 hours
  allowable amount.                                       from receipt of the request.

   Prior Authorization is not required for these          PREADMISSION REVIEW –
   radiological services when obtained outside            HOSPITAL ADMISSIONS
   of California. See the "Out-Of-Area Pro-
   gram: The BlueCard" section of this booklet            Preadmission Review must be used for all Hos-
   for an explanation of how payment is made              pital admissions (except for Admissions re-
   for out of state services.                             quired for Emergency Services). Included are
                                                          Hospitalizations for continuing Inpatient Reha-


                                                   -25-
bilitation or Rehabilitative Care. Whenever a                *Only one $250 Additional Payment will ap-
Hospital admission is recommended by your                    ply per Hospital admission for failure to no-
Physician, you or your Physician must con-                   tify Blue Shield or to follow a recommenda-
tact Blue Shield’s Medical Management Unit                   tion of Medical Management.              These
at 1-800-343-1691 at least 5 business days                   Additional Payments will be required in ad-
prior to the admission. However, in case of                  dition to any applicable Calendar Year de-
an admission for Emergency Services, Blue                    ductible, copayment and amounts in excess of
Shield should receive Emergency Admission                    benefit dollar maximums specified and will
Notification within 24 hours or by the end of                not be included in the calculation of the Sub-
the first business day following the admis-                  scriber’s Maximum Calendar Year Copay-
sion. Medical Management will discuss the                    ment responsibility.
benefits available, review the medical informa-
tion provided and may recommend that to ob-                  EMERGENCY ADMISSION NOTIFICATION
tain the full benefits of this health plan that the
services be performed on an Outpatient basis.                If you are admitted for Emergency Services,
                                                             Blue Shield should receive Emergency Admis-
Examples of procedures that may be recom-                    sion Notification within 24 hours or by the end
mended to be performed on an Outpatient basis                of the first business day following the admis-
if medical conditions do not indicate Inpatient              sion, or as soon as it is reasonably possible to do
care include:                                                so, whichever is later or you may be responsi-
1. Biopsy of lymph node, deep axillary;                      ble for the Additional Payment as described un-
                                                             der the Preadmission Review-Hospital Admis-
2. Hernia repair, inguinal;                                  sions paragraphs of this section.

3. Esophagogastroduodenoscopy with biopsy;
                                                             HOSPITAL INPATIENT UTILIZATION
4. Excision of ganglion;                                     REVIEW
5. Repair of tendon;                                         Blue Shield monitors Inpatient stays. The stay
                                                             may be extended or reduced as warranted by
6. Heart catheterization;                                    your condition, except in situations of maternity
                                                             admissions for which the length of stay is 48
7. Diagnostic bronchoscopy;
                                                             hours or less for a normal, vaginal delivery or
8. Creation of arterial venous shunts (for he-               96 hours or less for a Cesarean section unless
   modialysis).                                              the attending physician, in consultation with the
                                                             mother, determines a shorter hospital length of
Failure to contact medical management as                     stay is adequate. Also, for mastectomies or
described above or failure to follow the rec-                mastectomies with lymph node dissections, the
ommendations of medical management will                      length of hospital stays will be determined
result in an additional payment per hospital                 solely by your Physician in consultation with
admission as described below and may also                    you. When a determination is made that the
result in reduction or non-payment if Blue                   Person no longer requires the level of care
Shield determines that the admission is not a                available only in an Acute Care Hospital, writ-
covered service.                                             ten notification is given to you and your Doctor
                                                             of Medicine. You will be responsible for any
♦ *$250 per Hospital admission except for                    Hospital charges Incurred beyond 24 hours
  Hospital Admissions for Inpatient care for                 of receipt of notification.
  diagnosis or treatment of substance abuse.



                                                      -26-
DISCHARGE PLANNING                                           satisfied. No more than $3,000 is required of a
                                                             family in a Calendar Year. The Calendar Year
If further care at home or in another facility is            deductible does not count toward the Maximum
appropriate following discharge from the Hos-                Calendar Year Copayment responsibility.
pital, Blue Shield will work with the Physician
and Hospital discharge planners to determine                 Services Not Subject to the Deductible
whether benefits are available under this plan to
cover such care.                                             The Calendar Year deductible applies to all
                                                             covered Services Incurred during a Calendar
CARE MANAGEMENT                                              Year except the following:

The Benefits Management Program may also                     The Calendar Year deductible does not apply
include care management, which provides as-                  to:
sistance in making the most efficient use of plan            1. Preventive Care Benefits for the following
benefits. Individual care management may also,                  Services:
when it is determined to be appropriate through
a Blue Shield of California review, arrange for                 Annual Health Appraisal Exam Services in-
alternative care benefits in place of prolonged or              cluding,
repeated hospitalizations. Such alternative care                      annual physical examination,
benefits will be available only by mutual con-                        routine laboratory Services,
sent of all parties and, if approved, will not ex-                    mammography and Papanicolaou's
ceed the benefit to which you would otherwise                         test;
have been entitled under this plan. Blue Shield
is not obligated to provide the same or similar                 Well Baby Care office visits;
alternative care benefits to any other person in                the Preventive Care Sigmoidoscopy;
any other instance. The approval of alternative
care benefits will be for a specific period of time          2. Family Planning counseling and consulta-
and will not be construed as a waiver of Blue                   tion Services;
Shield’s right to thereafter administer this health          3. Preferred Physician office visits, including
plan in strict accordance with its express terms.               mammography and Papanicolaou’s test.
                                                                However, other covered Services received
DEDUCTIBLE                                                      during or in connection with a Preferred
                                                                Physician office visit are subject to the Cal-
                                                                endar Year deductible;
1. Calendar Year Deductible,
   $1,000 per Person                                         4. Emergency Room Facility Services not re-
                                                                sulting in an admission.
After the Calendar Year deductible is satisfied
for those Services to which it applies, benefits
will be provided for covered Services. This de-              ADDITIONAL AND REDUCED PAYMENTS
ductible must be made up of charges covered by               FOR FAILURE TO USE THE BENEFITS
the plan. Charges in excess of the Allowable
Amount do not apply toward the deductible. The
                                                             MANAGEMENT PROGRAM
deductible must be satisfied once during each                An Additional Payment of $250 may be re-
Calendar Year by or on behalf of each Person                 quired in addition to the applicable Calendar
separately, except that the deductible shall be              Year payment described above. This Additional
deemed satisfied with respect to the Subscriber              Payment will be applicable to Hospital Inpatient
and all of his covered Dependents collectively               charges when a Subscriber or Dependent fails to
after the family deductible amount has been                  follow the procedures described under the Pre-

                                                      -27-
admission Review section of the Benefits Man-             Maximum Calendar Year Copayment re-
agement Program.                                          sponsibility.
Only one $250 Additional Payment will apply
to each Hospital admission for failure to follow          MAXIMUM AGGREGATE PAYMENT
the Benefits Management Program notification              AMOUNT
requirements or recommendations.
                                                          The maximum aggregate payment amount is
Failure to receive prior authorization for the            $2,000,000. Benefits in excess of this amount
radiological procedures listed in the Benefits            will not be provided to you or on your behalf.
Management Program section or to follow
the recommendations of Blue Shield will re-               This maximum aggregate payment amount is
sult in reduced payment amounts per proce-                determined by totaling all Blue Shield benefits
dure and may result in non-payment for pro-               provided for you or on your behalf, whether you
cedures which are determined not to be                    are a Subscriber or a Dependent, while covered
covered Services.                                         under this plan, or any prior or subsequent plan
                                                          with Blue Shield.
♦ For covered Services that are not author-
  ized in advance, the amount payable will
  be reduced by 50% after the calculation                 PAYMENT
  of the deductible and any applicable
  copayments required by this plan. You                   Blue Shield Payment
  will be responsible for the remaining 50%               and Subscriber Copayment
  and applicable deductible and/or copay-                 Responsibilities for Covered Services
  ments. This additional 50% responsibility
  will not be included in the calculation of              Subject to all requirements of the Benefits Man-
  the Subscriber’s Maximum Calendar                       agement Program as shown in the Summary of
  Year Copayment responsibility;                          Benefits, and after all applicable deductibles
                                                          have been satisfied, benefits are provided for
♦ For services provided by a Non-Preferred                covered Services as follows:
  Provider, the Subscriber will also be re-
  sponsible for all charges in excess of the              Physician Services
  Allowable Amount.
                                                          1. Services rendered by a Participating Physi-
Failure to receive Prior Authorization or to                 cian are paid at 80% of the Allowable
follow the recommendations of Blue Shield                    Amount. Subscribers are responsible for the
for covered, Medically Necessary enteral                     remaining 20% of the Allowable Amount.
formulas and Special Food Products for the
treatment of phenylketonuria (PKU) will re-               2. Services rendered by a Non-Participating
sult in a 50% reduction in the amount pay-                   Physician are paid at 70% of the Allowable
able by Blue Shield after the calculation of                 Amount. Subscribers are responsible for the
the deductible and any applicable copay-                     remaining 30% of the Allowable Amount, as
ments required by this plan. You will be re-                 well as any charges above the Allowable
sponsible for the applicable deductibles                     Amount.
and/or copayments and the additional 50% of               Payment for covered Services is limited to the
the charges that are payable under this plan.             lesser of the benefit maximum for Services
The additional 50% responsibility will not be             specified under the Covered Services section
included in the calculation of the Subscriber’s           of this booklet or the applicable payment for
                                                          the Services as specified above.


                                                   -28-
Preferred Physicians have agreed to accept Blue                   Hospital will be less than 24 hours. The
Shield's payment, plus applicable deductibles                     covered Person or the attending Doctor
and copayments, as payment-in-full for cov-                       of Medicine must notify Blue Shield of
ered Services. Subscribers are not responsible                    California within 24 hours or by the end
to Preferred Physicians for payment of covered                    of the first business day following the
Services, except for applicable deductibles,                      admission for Emergency Services and
copayments, or amounts in excess of specified                     make arrangements for the transfer to a
maximums and except as provided under the                         Preferred Hospital.
Exception for Other Coverage provision.                       b. For non-Emergency Inpatient and Out-
If the Subscriber or Dependent recovers from a                   patient Services, benefits are paid at
third party the reasonable value of Services ren-                70% of allowed charges of no more than
dered by a Preferred Physician, the Preferred                    $600 per Person per day. Subscribers
Physician who rendered such Services is not re-                  are responsible for the remaining 30% of
quired to accept the amount paid by Blue Shield                  the $600, as well as all charges in excess
as payment-in-full, but may collect from the                     of $600.
Subscriber or Dependent the difference, if any,
                                                           Benefits for covered Services are substan-
between the amount paid by Blue Shield and the
                                                           tially reduced when Services are provided by
amount collected by the Subscriber or Depend-
                                                           a Non-Preferred Hospital. To avoid these
ent for such Services.
                                                           payment limitations, it is to the Person's ad-
A Physician Member or other Participating Phy-             vantage to use Preferred Hospitals. Pre-
sician may seek reimbursement from other third             ferred Hospitals accept Blue Shield of Cali-
party payors for the balance of its reasonable             fornia's negotiated amount plus the
charges for Services rendered under this plan.             applicable deductibles and copayment
                                                           amounts as payment-in-full for covered
Hospital Services                                          Services.

1. Rendered by a Preferred Hospital:                       Additionally, the Person's copayment for
                                                           Non-Preferred Hospital Outpatient Services,
   Benefits are paid at 80% of the lesser of               except for surgery and Emergency Services,
   Billed Charges or the negotiated rate. Sub-             does not apply toward the Person's maxi-
   scribers are responsible for the remaining              mum Calendar Year copayment amount.
   20%.
                                                           Services of Alternate Care Services
2. Rendered by a Non-Preferred Hospital:                   Providers
   a. For Emergency Services or for covered
                                                           Alternate Care Services Providers include Home
      Services not available in a Preferred
                                                           Medical Equipment suppliers, individual certi-
      Hospital, subject to Blue Shield's Pre-
                                                           fied orthotists, prosthetists and prosthetist-
      admission Review and other applicable
                                                           orthotists.
      requirements, benefits are paid at 80% of
      Billed Charges. Subscribers are respon-              1. Services rendered by Participating Alternate
      sible for the remaining 20% of Billed                   Care Services Providers are paid at 80% of
      Charges.                                                the Allowable Amount.* Subscribers are re-
       If a covered Person is admitted for                    sponsible for the remaining 20% of the Al-
       Emergency Services, he or she should be                lowable Amount.
       transferred to a Preferred Hospital as              2. Services rendered by Non-Participating Al-
       soon as he or she is stable, unless the                ternate Care Services Providers are paid at
       continued stay in the Non-Preferred                    70% of the Allowable Amount.* Subscrib-

                                                    -29-
   ers are responsible for the remaining 30% of              Allowable Amount. Subscribers are respon-
   the Allowable Amount, as well as any                      sible for the remaining 20% of the Allow-
   charges above the Allowable Amount.                       able Amount.
*Note: for all Services covered under the Ortho-          2. Services rendered by Non-Participating
ses Benefit Subscribers have a combined $2,000               Ambulatory Surgery Centers are paid at
per Person per Calendar Year benefit maximum.                70% of the Allowable Amount of no more
This maximum does not apply to Services cov-                 than $600 per Person per day. Subscribers
ered under the Prosthetic Appliances and Home                are responsible for the remaining 30% of the
Medical Equipment Benefits or the Diabetes                   Allowable Amount, as well as any charges
Care benefit.                                                above the Allowable Amount. (See Covered
                                                             Services for Services which are not covered
Services by Participating Home Health                        when rendered by Non-Participating Provid-
Care and Home Infusion Agencies and                          ers.)
PKU Related Formulas and Special Food
                                                          Benefits are substantially reduced when cov-
Products                                                  ered Services are provided by a Non-
1. Services rendered by Participating Home                Participating Ambulatory Surgery Center.
   Health Care and Home Infusion agencies are             To avoid these payment limitations, it is to
   paid at 80% of the Allowable Amount. Sub-              the Person's advantage to use Participating
   scribers are responsible for the remaining             Ambulatory Surgery Centers. Participating
   20% of the Allowable Amount.                           Ambulatory Surgery Centers accept Blue
                                                          Shield's negotiated rate as payment-in-full
2. Services rendered by Non-Participating                 for covered Services.
   Home Health Care and Home Infusion
   agencies are not covered, unless prior                 Additionally, the Person's copayment for
   authorized by Blue Shield.*                            Non-Participating Ambulatory Surgery Cen-
                                                          ter Services does not apply toward the Per-
   *If prior authorized by Blue Shield, Non-              son's maximum Calendar Year copayment
   Participating Providers will be reimbursed at          amount.
   a rate determined by the agency and Blue
   Shield. and the Subscriber copayment will              Services by Hospice Agencies
   be 20% of the determined rate, the Partici-
   pating Provider level                                  1. Services rendered by Participating Hospice
                                                             Agencies are paid as follows:
3. Benefits for Medically Necessary enteral
   formulas and Special Food Products for the                a. Continuous Home Care provided during
   treatment of phenylketonuria (PKU) are paid                  a Period of Crisis is paid at 80% of the
   at 80% of Billed Charges. Subscribers are                    Allowable Amount. Subscribers are re-
   responsible for the remaining 20%.                           sponsible for the remaining 20% of the
                                                                Allowable Amount.
All Home Health Care and Home Infusion
                                                             b. General Inpatient care is paid at 80% of
Services and PKU Related Formulas and
                                                                the Allowable Amount. Subscribers are
Special Food Products must be prior author-
                                                                responsible for the remaining 20% of the
ized by Blue Shield.
                                                                Allowable Amount.
Services by Ambulatory Surgery Centers                       c. Inpatient Respite Care is paid at 100% of
                                                                the Allowable Amount.
1. Services rendered by Participating Ambula-
   tory Surgery Centers are paid at 80% of the               d. Routine home care is paid at 100% of
                                                                the Allowable Amount.

                                                   -30-
2. Services rendered by Non-Participating                  Acupuncture Services
   Hospice Agencies are not covered, unless
   prior authorized by Blue Shield.                        Benefits are limited to a maximum of 20 visits.

   If Blue Shield prior authorizes Hospice                 1. Services rendered by a Preferred Provider
   Services from a Non-Participating Hospice                  are paid at 80% of the Allowable Amount.
   Agency, those Hospice Services will be re-                 Subscribers are responsible for the remain-
   imbursed at the Participating Hospice                      ing 20% of the Allowable Amount.
   Agency level, as described in item 1. above
                                                           2. Services rendered by a Non- Preferred Pro-
   at the payment rates negotiated between
                                                              vider are not covered.
   Blue Shield and the Non-Participating Hos-
   pice Agency.
                                                           Chiropractic Services
Note: All Hospice Program Services must be
prior authorized by Blue Shield. See Hospice               Benefits are limited to a maximum of 20 visits.
Program Services in the Covered Services sec-              1. Services rendered by a Preferred Provider
tion for a complete description of covered Hos-               are paid at 80% of the Allowable Amount.
pice Services and Hospice Program require-                    Subscribers are responsible for the remain-
ments.                                                        ing 20% of the Allowable Amount.

Services by Other Providers                                2. Services rendered by a Non- Preferred Pro-
                                                              vider are not covered.
Other Providers are paid at 80% of the lesser of
Billed Charges or the amount that Blue Shield              Out-of-Area Program: The BlueCard
of California determines was being charged by
the majority of providers of like covered Serv-            Benefits will be provided, according to para-
ices and supplies at the time and in the area              graphs (1.), (2.) and (3.) below, for covered
where the Services or supplies were provided.              Services received outside of California within
Subscribers are responsible for all remaining              the United States. Blue Shield of California
amounts.                                                   calculates the Subscriber's copayment as a per-
                                                           centage of the Allowable Amount, as defined in
Services by Other Providers are benefits only to           this booklet. When covered Services are re-
the extent that such Services are covered under            ceived in another state, the Subscriber's copay-
the plan.                                                  ment will be based on the local Blue Cross Blue
                                                           Shield plan's arrangement with its providers.
Radiological Procedures
                                                           1. Covered Services received from a provider
The radiological procedures which are listed in               who has contracted with the local Blue
the Benefits Management Program section re-                   Cross Blue Shield plan are paid at the Pre-
quire prior authorization by Blue Shield. Failure             ferred level. Subscribers are responsible for
to obtain this authorization will result in the               the remaining copayment.
Service being paid at a reduced amount or may
result in non-payment for procedures which are             2. Non-emergency covered Services received
determined not to be covered Services.                        from providers who have not contracted
                                                              with the local Blue Cross Blue Shield plan
See the Benefits Management Program section                   are paid at the Non-Preferred level of Blue
for complete information.                                     Shield's Allowable Amount. Subscribers are




                                                    -31-
   responsible for the remaining copayment as              directly. You may be asked to pay for your ap-
   well as any charges in excess of Blue                   plicable copayment and plan deductible at the
   Shield's Allowable Amount.                              time you receive the service.
3. Emergency Services received from provid-                You will receive an Explanation of Benefits
   ers who have not contracted with the local              which will show your payment responsibility.
   Blue Cross Blue Shield plan are paid at the             You are responsible for the copayment and plan
   Preferred level of Billed Charges. Subscrib-            deductible amounts shown in the Explanation of
   ers are responsible for the remaining                   Benefits.
   copayment.
                                                           Preadmission review is required for all inpatient
If you do not see a Participating Provider                 hospital services and notification is required for
through the BlueCard Program, you will have to             inpatient emergency services. Preservice review
pay for the entire bill for your medical care and          is required for selected inpatient and outpatient
submit a claim form (with a copy of the bill) to           services, supplies and home medical equipment.
Blue Shield of California for payment. Blue                To receive preadmission or preservice review
Shield will notify you of its determination                from Blue Shield of California, the out-of-area
within 30 days after receipt of the claim. Blue            provider should call 1-800-343-1691.
Shield will pay you at the Non-Preferred Pro-
vider benefit level. Remember, your copayment              If you need Emergency Services, you should
is higher when you see a Non-Preferred Pro-                seek immediate care from the nearest medical
vider. You will be responsible for paying the              facility. The benefits of this plan will be pro-
entire difference between the amount paid by               vided for covered Services received anywhere in
Blue Shield of California and the amount billed.           the world for emergency care of an illness or
                                                           injury.
Charges for Services which are not covered,
and charges by Non-Preferred Providers in                  Care for Covered Urgent Care and Emer-
excess of the amount covered by the plan, are              gency Services Outside the United States
the Subscriber's responsibility and are not
                                                           Benefits will also be provided for covered
included in copayment calculations.                        Services received outside of the United States
To receive the maximum benefits of your plan,              through the BlueCard Worldwide Network. If
please follow the procedure below.                         you need urgent care while out of the country,
                                                           call either the toll-free BlueCard Access number
When you require covered Services while trav-              at 1-800-810-2583 or call collect at 1-804-673-
eling outside of California:                               1177, 24 hours a day, seven days a week. In an
                                                           emergency, go directly to the nearest hospital. If
1. call BlueCard Access at 1-800-810-BLUE                  your coverage requires precertification or prior
   (2583) to locate physicians and hospitals               authorization, you should call Blue Shield of
   that participate with the local Blue Cross              California at 1-800-343-1691. For inpatient
   Blue Shield plan;                                       hospital care at participating hospitals, show
                                                           your I.D. card to the hospital staff upon arrival.
2. visit the Participating Physician or Hospital
                                                           You are responsible for the usual out-of-pocket
   and present your membership card.
                                                           expenses (non-covered charges, deductibles, and
The Participating Physician or Hospital will               copayments).
verify your eligibility and coverage information
                                                           When you receive services from a physician,
by calling BlueCard Eligibility at 1-800-676-
                                                           you will have to pay the doctor and then submit
BLUE. Once verified and after Services are
                                                           a claim. Also for hospitalization, if you do not
provided, a claim is submitted electronically and
                                                           use the BlueCard Worldwide Network, you will
the Participating Physician or Hospital is paid
                                                           have to pay the entire bill for your medical care

                                                    -32-
and submit a claim form (with a copy of the bill)           Statutes in a small number of states may require
to Blue Shield of California.                               the Host Blue to use a basis for calculating Sub-
                                                            scriber liability for covered Services that does
Before traveling abroad, call your local Cus-               not reflect the entire savings realized, or ex-
tomer Service office for the most current listing           pected to be realized, on a particular claim or to
of participating hospitals world-wide wide and              add a surcharge. Should any state statutes man-
to obtain a copy of the BlueCard Worldwide                  date Subscriber liability calculation methods
Network brochure that provides helpful infor-               that differ from the usual BlueCard method
mation on receiving covered services in a for-              noted above or require a surcharge, Blue Shield
eign country or you can visit Blue Shield’s                 of California would then calculate your liability
internet site at http://www.mylifepath.com.                 for any covered health care services in accor-
                                                            dance with the applicable state statute in effect
Calculation of your deductibles, copayments
                                                            at the time you received your care.
and maximum copayment responsibilities under
the BlueCard Program:
                                                            MAXIMUM CALENDAR YEAR
When you obtain health care services through                COPAYMENT RESPONSIBILITY
BlueCard outside the geographic area Blue
Shield of California serves, the amount you pay             The maximum copayment required each Calen-
for covered services is calculated on the lower             dar Year for covered Services by Preferred Pro-
of:                                                         viders, and Other Providers is $6,000 per Per-
                                                            son, not to exceed $18,000 per family.
1. The billed charges for your covered serv-
   ices, or                                                 The maximum copayment required each Calen-
                                                            dar Year for covered Services by Non-Preferred
2. The negotiated price that the on-site Blue               Providers, and Other Providers is $9,000 per
   Cross and/or Blue Shield plan (“Host Blue”)              Person, not to exceed $27,000 per family.
   passes on to us.
                                                            The total maximum copayment required each
Often, this "negotiated price" will consist of a            Calendar Year for covered Services by any
simple discount which reflects the actual price             combination of Preferred Providers, Non-
paid by the Host Blue. But sometimes it is an               Preferred Providers and Other Providers is
estimated price that factors into the actual price          $9,000 per Person, not to exceed $27,000 per
expected settlements, withholds, any other con-             family.
tingent payment arrangements and non-claims
transactions with your health care provider or              Once the Subscriber’s Maximum Calendar Year
with a specified group of providers. The nego-              Copayment Responsibility has been met, Blue
tiated price may also be billed charges reduced             Shield will pay 100% of the Allowable Amount
to reflect an average expected savings with                 for the Subscriber’s covered Services for the
your health care provider or with a specified               remainder of that Calendar Year.
group of providers. The price that reflects aver-
age savings may result in greater variation                 The following Subscriber financial responsi-
(more or less) from the actual price paid than              bilities are not included in the calculation of
will the estimated price. The negotiated price              the Maximum Calendar Year Copayment:
will also be adjusted in the future to correct for
                                                            1. Preventive Care Benefits Services for the
over- or underestimation of past prices. How-
                                                               Annual routine physical exam (includes
ever, the amount you pay is considered a final
                                                               eye/ear screening, immunizations, vaccina-
price.
                                                               tions);




                                                     -33-
2. Well baby care office visits and consulta-              procedure for requesting continuity of care from
   tions;                                                  a terminated provider.
3. Family Planning counseling and consulta-                PLEASE READ THE FOLLOWING INFOR-
   tion Services;                                          MATION SO YOU WILL KNOW FROM
                                                           WHOM OR WHAT GROUP OF PROVIDERS
4. Physician office visits and consultations,              HEALTH CARE MAY BE OBTAINED.
   specialist visits and consultations;

5. Emergency Room Facility Services not re-                PREFERRED PROVIDER BENEFIT
   sulting in an admission;                                FEATURES
6. the Calendar Year deductible;                           Preferred Providers submit claims for payment
                                                           after their services have been received. You or
7. charges by Non-Preferred Providers in ex-
                                                           your Non-Preferred Providers also submit
   cess of Allowable Amounts;
                                                           claims for payment after services have been re-
8. charges in excess of specified benefit maxi-            ceived.
   mums;
                                                           Providers do not receive financial incentives or
9. Non-Preferred Hospital and Professional                 bonuses from Blue Shield of California.
   Services (except for Emergencies);
                                                           This plan is most effective and advantageous
10. Non-Preferred   Skilled   Nursing    Facility          when the Services of Participating Physicians
    Services;                                              and Participating Hospitals are used. You re-
                                                           ceive the maximum benefits of the plan when
11. Non-Participating    Ambulatory      Surgery           you select these providers.
    Center Services;
                                                           You are responsible for a lower copayment per-
12. Additional and Reduced Payments under the
                                                           centage when Preferred Providers are seen. Pre-
    Benefits Management Program.
                                                           ferred Providers include Preferred Physicians,
For those services listed above that do not                Participating Alternate Care Services Providers
count toward and are not waived by reaching                and Participating Ambulatory Surgery Centers.
a Maximum Calendar Year Copayment re-
                                                           Participating Providers and Preferred Providers
sponsibility amount, a Subscriber will con-
                                                           have agreed to accept Blue Shield's payment,
tinue to pay for those services after they
                                                           plus applicable deductibles and copayments as
reach a Maximum Calendar Year Copay-
                                                           payment-in-full for covered Services, except as
ment responsibility amount.
                                                           provided under the Exception for Other Cover-
                                                           age provision and for amounts in excess of
CONTINUITY OF CARE BY A TERMINATED                         specified benefit maximums. You are not liable
PROVIDER                                                   to these providers for any amounts payable by
                                                           Blue Shield for covered Services. Blue Shield
Subscribers who are being treated for acute                payment for Services by Non-Preferred Provid-
conditions, serious chronic conditions, high-risk          ers generally will be less than payments for the
pregnancies or pregnancies that have reached               same Services when provided by a Participating
the second or third trimester can request con-             Provider, and could result in substantial addi-
tinuation of covered Services in certain situa-            tional out-of-pocket expense. You are responsi-
tions with a provider who is terminated. Contact           ble for all balances when Services are rendered
Customer Service to receive information re-                by a Non-Preferred Provider.
garding eligibility criteria and the policy and



                                                    -34-
You and your Dependent must determine if your               PRINCIPAL BENEFITS AND COVERAGES
Physician, Hospital, or other provider is a Par-
ticipating or Preferred Provider. Participating or          (COVERED SERVICES)
Preferred Providers are paid directly by Blue               Benefits are provided for the following covered
Shield.                                                     Services, subject to applicable deductibles,
You are paid directly by Blue Shield if Services            copayments and charges in excess of benefit
are rendered by a Non-Preferred Provider.                   maximums, Preferred Provider provisions,
Payments to you for covered Services are in                 Benefits Management Program provisions, and
amounts identical to those made directly to pro-            other limitations and exclusions.
viders. Requests for payment must be submitted
to Blue Shield within 1 year after the month                HOSPITAL BENEFITS
Services were provided. Special claim forms                 (Other than Hospice Program Services which
are not necessary, but each claim submission                is described in a subsequent section.)
must contain your name, home address, group
contract number, Subscriber's number, a copy of             Inpatient Services
the provider's billing showing the Services ren-            for Treatment of Illness or Injury
dered, dates of treatment and the patient's name.
Blue Shield will notify you of its determination            1. Any accommodation up to the Hospital's
within 30 days after receipt of the claim.                     established semi-private room rate, or, if
                                                               medically necessary as certified by a Doctor
You are not responsible to Participating and                   of Medicine, the intensive care unit.
Preferred Providers for payment for covered
Services, except for the deductibles, copay-                2. Use of operating room and specialized
ments, and amounts in excess of specified bene-                treatment rooms.
fit maximums, and except as provided under the
Exception for Other Coverage provision.                     3. In conjunction with a covered delivery, rou-
                                                               tine nursery care for a newborn of the Sub-
If you or your Dependent are receiving Services                scriber or covered spouse.
from a Participating or Preferred Provider as of
the date that such provider's contract with Blue            4. Surgical supplies, dressings and cast materi-
Shield is terminated, the responsibility of you or             als, and anesthetic supplies furnished by the
your Dependent to that provider for Services                   Hospital.
rendered subsequent to that termination date                5. Physical Medicine - including hydrotherapy
shall be no greater than it was for Services ren-              - when furnished by the Hospital, and Reha-
dered immediately prior to that termination date,              bilitative Care when furnished by the Hos-
until the first to occur of the following:                     pital and approved in advance by Blue
1. the date that the Services being rendered by                Shield under its Benefits Management Pro-
   such provider are completed;                                gram.

2. the date that Blue Shield makes reasonable               6. Drugs and oxygen.
   and medically appropriate provision for the              7. Administration of blood and blood plasma,
   assumption of such Services by another Par-                 including the cost of blood, blood plasma
   ticipating or Preferred Provider;                           and blood processing.
3. the date that coverage for you or your De-               8. X-ray examination and laboratory tests.
   pendent is terminated.




                                                     -35-
9. Radiation therapy, renal dialysis treatment              SKILLED NURSING FACILITIES BENEFITS
   and chemotherapy for cancer including                    (Other than Hospice Program Services which
   catheterization, infusion devices, and associ-           is described in a subsequent section.)
   ated drugs and supplies.
                                                            Benefits are provided for confinement in a
10. Use of medical appliances and equipment.                Skilled Nursing Facility if necessary in lieu of
                                                            Hospital confinement, for the treatment of an
11. Subacute Care.                                          illness or injury, including Subacute Care, up to
12. Inpatient Services including general anes-              a benefit maximum of 100 days per Person per
    thesia and associated facility charges in con-          Calendar Year, except that room and board
    nection with dental procedures when hospi-              charges in excess of the facility's established
    talization is required because of an                    semi-private room rate are excluded.
    underlying medical condition or clinical
    status and the Person is under the age of               SURGICAL BENEFITS
    seven or developmentally disabled regard-
    less of age or when the Person’s health is              When surgery is performed for the treatment of
    compromised and for whom general anes-                  an illness or injury, benefits are provided for:
    thesia is medically necessary regardless of
                                                            1. Surgeons (M.D. or D.O.);
    age. Excludes dental procedures and serv-
    ices of a dentist or oral surgeon.                      2. Assistant surgeons;
13. Medically Necessary substance abuse de-                 3. Anesthesiologists;
    toxification.
                                                            4. Consultants — during and after an opera-
Outpatient Services                                            tion;
for Treatment of Illness or Injury
                                                            5. Podiatrists.
1. Medically necessary Services provided in
                                                            When multiple surgical procedures are per-
   the Outpatient Facility of a Hospital.
                                                            formed during the same operation, benefits for
2. Outpatient care provided by the admitting                the secondary procedure(s) will be determined
   Hospital within 24 hours before admission,               based on Blue Shield of California Medical
   when care is related to the condition for                Policy. No benefits are provided for secondary
   which Inpatient admission was made.                      procedures which are incident to, or an integral
                                                            part of, the primary procedure.
3. Physical Medicine.
4. Outpatient Services including general anes-              AMBULATORY SURGICAL BENEFITS
   thesia and associated facility charges in con-           The Hospital and surgical benefits of this plan
   nection with dental procedures when per-                 are provided whenever care is rendered in a
   formed in the Outpatient Facility of a                   freestanding ambulatory facility (including a
   Hospital because of an underlying medical                Physician's office) or a short stay surgical unit,
   condition or clinical status and the Person is           or Outpatient unit of a Hospital, when those
   under the age of seven or developmentally                Services are medically necessary as determined
   disabled regardless of age or when the Per-              by Blue Shield. Ambulatory surgery Services
   son’s health is compromised and for whom                 means surgery which does not require admission
   general anesthesia is medically necessary                to a Hospital (or similar facility) as a registered
   regardless of age. Excludes dental proce-                bed patient.
   dures and services of a dentist or oral sur-
   geon.

                                                     -36-
Outpatient Services including general anesthesia            1. One annual Mammography and Papanico-
and associated facility charges in connection                  laou's Test (Pap test) or other FDA (Food
with dental procedures are covered when per-                   and Drug Administration) approved cervical
formed in an ambulatory surgery center because                 cancer screening test for screening purposes.
of an underlying medical condition or clinical
status and the Person is under the age of seven             2. Family planning and consultation Services,
or developmentally disabled regardless of age or               including voluntary sterilization (tubal liga-
when the Person’s health is compromised and                    tion and vasectomy) and elective abortions.
for whom general anesthesia is medically neces-                No benefits are provided for contraceptives.
sary regardless of age. Excludes dental proce-                 Physician office visits for diaphragm fittings
dures and Services of a dentist or oral surgeon.               are covered.
                                                            3. Colorectal Cancer Screening
MEDICAL BENEFITS
(Other than Preventive Care and Hospice                        For age 50 and older, benefits are provided
Program Services which are described in a                      for:
subsequent section.)                                           a. flexible sigmoidoscopy every 5 years,
Benefits are provided for Services of Physicians               b. double contrast barium enema every 5 to
for treatment of illness or injury, and for treat-                10 years,
ment of physical complications of a mastec-
tomy, including lymphedemas, including:                        c. colonoscopy every 10 years.

1. Visits to the office, home, Hospital or                  4. For Subscribers and Dependents age 3 and
   Skilled Nursing Facility, beginning with the                over, Benefits are provided for one Annual
   first visit;                                                Health Appraisal Exam in a Calendar Year.

2. Extra time spent when a Physician is de-                    Annual Health Appraisal Exams include the
   tained to treat a Person in critical condition;             following Services:
                                                               a. annual routine physical examinations;
3. Services of consultants, including those for
   second medical opinion consultations;                       b. routine laboratory Services based on Blue
                                                                  Shield’s Preventive Health Guidelines.
4. Necessary preoperative treatment;                              These guidelines are derived from the US
5. Radiotherapy, radium therapy, radioisotope                     Preventive Services Task Force, Advisory
   therapy and X-ray therapy for treatment of                     Committee on Immunization Practices and
   benign and malignant diseases;                                 Centers for Disease Control and Preven-
                                                                  tion recommendations. Except for routine
6. Treatment of burns;                                            Pap tests or other FDA (Food and Drug
                                                                  Administration) approved cervical cancer
7. Services in connection with kidney dialysis;                   screening tests which are covered as indi-
                                                                  cated in item c. below, routine laboratory
8. Outpatient Physical Medicine Services;
                                                                  Services include but are not limited to:
9. Allergy testing and treatment.                                  1) tuberculin test,

PREVENTIVE CARE BENEFITS                                           2) screening for blood lead levels in
                                                                      children at risk for lead poisoning, as
Benefits are provided for the following Services                      determined and prescribed by a
without illness or injury being present:                              Doctor of Medicine,



                                                     -37-
       3) venereal disease tests as recom-                (Note: certain radiological procedures require
          mended in Blue Shield’s Preventive              prior authorization by Blue Shield. See the
          Health Guidelines,                              Benefits Management Program section for com-
                                                          plete information.)
       4) fecal occult blood test (FOBT) for
          age 50 and older.
                                                          CHEMOTHERAPY BENEFITS
   c. pediatric and adult immunizations and
      the immunizing agent as recommended                 Benefits are provided for Chemotherapy for
      by the American Academy of Pediatrics               cancer, when provided by a Physician in the
      and the United States Public Health                 Hospital, the Physician's office, or the Person's
      Service through its U. S. Preventive                home. Benefits include catheterization, Physi-
      Services Task Force and/or the Advisory             cian visits, drugs and solutions, and infusion de-
      Committee on Immunization Practices                 vices and servicing. High-dose chemotherapy
      (ACIP) of the Centers for Disease Con-              (which requires collection and reinfusion of a
      trol (CDC);                                         patient's own blood products as a supportive
                                                          measure) is a benefit only when provided in
   e. eye and ear screenings to determine the             connection with those certain bone marrow
      need for eye refractions or audiograms              transplant procedures when authorized under the
      when provided to a Dependent child                  Special Transplant Benefits provision.
      through 18 years of age;
5. Osteoporosis Screening                                 ACUPUNCTURE BENEFITS
   Benefits are provided for osteoporosis                 Benefits are provided for acupuncture treatment
   screening for age 65 and older or 60 and               by a Doctor of Medicine (M.D.) or a certificated
   older if at increased risk.                            acupuncturist up to a benefit maximum of 20
                                                          visits for each Person during a Calendar Year.
6. Nurseline
   As part of Lifepath Advisers, Persons may              PROSTHETIC APPLIANCES AND HOME
   call a registered nurse via 1-866-543-3728, a          MEDICAL EQUIPMENT BENEFITS
   24-hour, toll-free number to receive confi-
   dential advice and information about minor             Benefits are provided for prosthetic appliances,
   illnesses and injuries, chronic conditions,            e.g., artificial limbs and eyes and their fitting;
   fitness, nutrition and other health related            Blom-Singer prostheses for speech following a
   topics. Services are provided at no charge to          laryngectomy; for oxygen and its administra-
   the Subscriber.                                        tion; rental of wheelchair, Hospital bed, and
                                                          other Home Medical Equipment, except that no
OUTPATIENT OR OUT-OF-HOSPITAL                             benefits are provided for rental charges in ex-
                                                          cess of the purchase cost. Prosthetic devices
X-RAY AND LABORATORY BENEFITS                             provided to restore and achieve symmetry inci-
Benefits are provided for diagnostic X-ray                dent to a mastectomy are covered.
Services, diagnostic examinations, and clinical
                                                          Benefits are provided at the most cost effective
laboratory Services, when provided to diagnose
                                                          level of care that is consistent with profession-
illness or injury. Routine laboratory services
                                                          ally recognized standards of practice. If there
performed as part of a preventive health
                                                          are two or more professionally recognized ap-
screening are covered under the Preventive Care
                                                          pliances equally appropriate for a condition,
Benefits section.




                                                   -38-
benefits will be based on the most cost effective            Benefits are provided only for orthotic de-
appliance. Initial fitting and replacement after             vices for maintaining normal Activities of
the expected life of the prosthesis is covered.              Daily Living. No benefits are provided for
                                                             orthotic devices such as knee braces intended
No benefits are provided for wigs for any                    to provide additional support for recreational
reason, environmental control equipment,                     or sports activities or for orthopedic shoes
generators, self-help/educational devices or                 and other supportive devices for the feet. No
any type of speech or language assistance de-                benefits are provided for backup or alternate
vices (except as specifically provided), air                 items.
conditioners, humidifiers, dehumidifiers, air
purifiers, exercise equipment, or any other                  There is a combined $2,000 per Person per
equipment not primarily medical in nature.                   Calendar Year maximum on all Orthotic de-
No benefits are provided for backup or alter-                vices covered under this benefit. This maxi-
nate items.                                                  mum does not apply to Services covered un-
                                                             der the Diabetes Care benefit.
Note: See the Diabetes Care section for de-
vices, equipment and supplies for the man-                   Note: See the Diabetes Care section for de-
agement and treatment of diabetes.                           vices, equipment and supplies for the man-
                                                             agement and treatment of diabetes.
For Persons in a Hospice Program through a
Participating Hospice Agency, medical
equipment and supplies that are reasonable                   DIABETES CARE
and necessary for the palliation and man-                    Benefits are provided for the following diabetes
agement of Terminal Illness and related con-                 care Services and supplies:
ditions are provided by the Hospice Agency.
                                                             1. Devices, equipment and supplies for the
ORTHOSES BENEFITS                                               management and treatment of diabetes when
                                                                medically necessary.
Benefits are provided for orthotic appliances,
including:                                                      a. blood glucose monitors, including those
                                                                   designed to assist the visually impaired;
1. shoes only when permanently attached to
   such appliances;                                             b. Insulin pumps and all related necessary
                                                                   supplies;
2. special footwear required for foot disfig-
   urement which includes, but is not limited                   c. podiatric devices to prevent or treat dia-
   to, foot disfigurement from cerebral palsy,                     betes-related complications, including
   arthritis, polio, spina bifida, and foot disfig-                extra-depth orthopedic shoes;
   urement caused by accident or develop-
                                                                d. visual aids, excluding eyewear, designed
   mental disability;
                                                                   to assist the visually impaired with
3. Medically necessary knee braces for post-                       proper dosing of Insulin (excluding
   operative rehabilitation following ligament                     video-assisted visual aids);
   surgery, instability due to injury, and to re-
                                                                e. Diabetic testing supplies (including lan-
   duce pain and instability for patients with
                                                                   cets, lancet puncture devices, and blood
   osteo-arthritis;
                                                                   and urine testing strips and test tablets).
4. initial fitting and replacement after the ex-
                                                             2. Diabetes outpatient self-management train-
   pected life of the orthosis is covered.
                                                                ing, education and medical nutrition therapy



                                                      -39-
   that is Medically Necessary to enable a Sub-             MEDICAL TREATMENT OF THE TEETH, GUMS,
   scriber to properly use the devices, equip-              OR JAW JOINTS AND JAW BONES BENEFITS
   ment and supplies, and any additional out-
   patient self-management training, education              Benefits are provided for Hospital and profes-
   and medical nutrition therapy when directed              sional Services provided for conditions of the
   or prescribed by the Person’s Physician.                 teeth, gums or jaw joints and jaw bones, in-
   These benefits shall include, but not be lim-            cluding adjacent tissues, only to the extent that
   ited to, instruction that will enable diabetic           they are provided for:
   patients and their families to gain an under-
   standing of the diabetic disease process, and            1. the treatment of tumors of the gums;
   the daily management of diabetic therapy, in
                                                            2. the treatment of damage to natural teeth
   order to thereby avoid frequent hospitaliza-
                                                               caused solely by an accidental injury is lim-
   tions and complications. Services will be
                                                               ited to Medically Necessary Services until
   covered when provided by Physicians, reg-
                                                               the Services result in initial, palliative stabi-
   istered dieticians or registered nurses who
                                                               lization of the Person as determined by the
   are certified diabetes educators.
                                                               Plan;

PREGNANCY BENEFITS                                             Note: Dental services provided after initial
                                                               medical stabilization, prosthodontics, ortho-
Benefits are provided for pregnancy and com-                   dontia and cosmetic services are not cov-
plications of pregnancy, including prenatal di-                ered. This benefit does not include damage
agnosis of genetic disorders of the fetus by                   to the natural teeth that is not accidental,
means of diagnostic procedures in cases of high-               e.g., resulting from chewing or biting.
risk pregnancy, and post-delivery care. No
benefits are provided for Services after termina-           3. medically necessary non-surgical treatment
tion of coverage under this plan unless the Per-               (e.g., splint and physical therapy) of Tempo-
son qualifies for an extension of benefits as de-              romandibular Joint Syndrome (TMJ);
scribed elsewhere in this booklet.
                                                            4. surgical and arthroscopic treatment of TMJ
Note: The Newborns’ and Mothers’ Health                        if prior history shows conservative medical
Protection Act requires group health plans to                  treatment has failed; or
provide a minimum hospital stay for the mother
and newborn child of 48 hours after a normal,               5. orthognathic surgery (surgery to reposition
vaginal delivery and 96 hours after a C-section                the upper and/or lower jaw) which is medi-
unless the attending physician, in consultation                cally necessary to correct a skeletal deform-
with the mother, determines a shorter hospital                 ity.
length of stay is adequate.
                                                            No benefits are provided for:
If the hospital stay is less than 48 hours after a
normal, vaginal delivery or less than 96 hours              1. Services customarily provided by dentists
after a C-section, a follow-up visit for the                   and oral surgeons, including hospitaliza-
mother and newborn within 48 hours of dis-                     tion incident thereto;
charge is covered when prescribed by the treat-
                                                            2. orthodontia (dental Services to correct ir-
ing physician. This visit shall be provided by a
                                                               regularities or malocclusion of the teeth)
licensed health care provider whose scope of
                                                               for any reason, including treatment to al-
practice includes postpartum and newborn care.
                                                               leviate TMJ;
The treating physician, in consultation with the
mother, shall determine whether this visit shall            3. dental implants (endosteal, subperiosteal
occur at home, the contracted facility, or the                 or transosteal);
physician’s office.

                                                     -40-
4. any procedure (e.g. vestibuloplasty) in-                   not Medically Necessary pursuant to the treat-
   tended to prepare the mouth for dentures                   ment plan, Blue Shield will notify the Sub-
   or for the more comfortable use of den-                    scriber of this determination and benefits will
   tures.                                                     not be provided for Services rendered after the
                                                              date of the written notification.
RECONSTRUCTIVE SURGERY                                        Note: See the Home Health Care, Home Infu-
Reconstructive Surgery and associated covered                 sion Care Benefits, and PKU Related For-
Services when determined by Blue Shield to be                 mulas and Special Food Products and the
Medically Necessary and only to correct or re-                Hospice Program Services sections for infor-
pair abnormal structures of the body and which                mation on coverage for Outpatient Physical
result in more than a minimal improvement in                  Medicine Services rendered in the home, in-
function or appearance. In accordance with the                cluding visit limits.
Women’s Health & Cancer Rights Act, Recon-
                                                              Services provided by a chiropractor are cov-
structive Surgery on either breast provided to
                                                              ered under Chiropractic Services.
restore and achieve symmetry incident to a
mastectomy is covered. Any such Services
must be received while the contract is in force               SPEECH THERAPY BENEFITS
with respect to the Person. Benefits will be pro-
                                                              Outpatient benefits are provided for Speech
vided in accordance with guidelines established
                                                              Therapy Services when referred by a Doctor of
by Blue Shield of California and developed in
                                                              Medicine and provided by a speech therapist
conjunction with plastic and reconstructive sur-
                                                              who holds an American Speech and Hearing
geons.
                                                              Association certificate of competence, pursuant
                                                              to a written treatment plan for as long as contin-
CHIROPRACTIC SERVICES                                         ued treatment is Medically Necessary, and when
                                                              rendered in the provider's office or Outpatient
Benefits are provided for any Medically Neces-
                                                              department of a Hospital. Services are provided
sary Chiropractic Services rendered by a chiro-
                                                              for the correction of the following:
practor. Benefits are limited to a maximum of
20 visits per Person per Calendar Year.                       1. speech impediment caused by documented
                                                                 illness or injury to the vocal organs, oral
OUTPATIENT PHYSICAL MEDICINE                                     cavity, or auditory canal; or
BENEFITS                                                      2. speech impediment due to:
Benefits are provided for Outpatient Physical                    a. stroke or injury to the brain;
Medicine provided by a Doctor of Medicine,
Doctor of Osteopathy, registered physical thera-                 b. corrective surgery        for    congenital
pist, certified occupational therapist, or certified                anomalies; and/or
respiratory therapist, pursuant to a written
                                                                 c. cerebral palsy.
treatment plan for as long as continued treat-
ment is Medically Necessary and, when ren-                    Benefits will be provided for medically neces-
dered in the provider's office or Outpatient de-              sary Services as long as continued treatment is
partment of a Hospital. Benefits will be                      Medically Necessary pursuant to the treatment
provided for medically necessary Services as                  plan. Blue Shield reserves the right to periodi-
long as continued treatment is Medically Neces-               cally review the provider’s treatment plan and
sary pursuant to the treatment plan. Blue Shield              records. If Blue Shield determines that contin-
reserves the right to periodically review the pro-            ued treatment is not Medically Necessary pursu-
vider’s treatment plan and records. If Blue                   ant to the treatment plan, Blue Shield will notify
Shield determines that continued treatment is                 the Member of this determination and benefits

                                                       -41-
will not be provided for services rendered after            Transplant Facility contracting with Blue Shield
the date of the written notification.                       of California to provide the procedure, or in the
                                                            case of Persons accessing this benefit outside of
Except as specified above and as stated under               California, the procedure is performed at a
the Home Health Care and Home Infusion Care                 transplant facility designated by Blue Shield, (2)
benefit and the Hospice Program Services bene-              prior authorization is obtained, in writing, from
fit, no benefits are provided for Speech Therapy,           Blue Shield's Medical Director and (3) the re-
speech correction, or speech pathology Services.            cipient of the transplant is a Subscriber or De-
No benefits are provided for the correction                 pendent.
of:
                                                            Blue Shield of California reserves the right to
1. stammering, stuttering, lisping, tongue                  review all requests for prior authorization for
   thrust, etc.,                                            these Special Transplant Benefits, and to make a
                                                            decision regarding benefits based on (1) the
2. speech impediments caused by functional
                                                            medical circumstances of each Person, and (2)
   nervous disorders, or
                                                            consistency between the treatment proposed and
3. developmental speech delays.                             Blue Shield of California medical policy. Fail-
                                                            ure to obtain prior written authorization as
Note: See the Home Health Care, Home Infu-                  described above and/or failure to have the
sion Care Benefits, and PKU Related For-                    procedure performed at a contracting Special
mulas and Special Food Products and the                     Transplant Facility will result in denial of
Hospice Program Services sections for infor-                claims for this benefit.
mation on coverage for Speech Therapy Serv-
ices rendered in the home, including visit limits.          The following procedures are eligible for cover-
                                                            age under this provision:
TRANSPLANT BENEFITS                                         1. Human heart transplants;

Organ Transplants                                           2. Human lung transplants;

Benefits are provided for Hospital and profes-              3. Human heart and lung transplants in combi-
sional Services provided in connection with                    nation;
human organ transplants only to the extent that:
                                                            4. Human liver transplants;
1. they are provided in connection with the
   transplant of a cornea, kidney or skin; and              5. Human kidney and pancreas transplants in
                                                               combination (pancreas only transplants are
2. the recipient of such transplant is a Sub-                  not covered);
   scriber or Dependent.
                                                            6. Human bone marrow transplants, including
Benefits are provided for Services incident to                 autologous bone marrow transplantation
obtaining the human organ transplant material                  (ABMT) or autologous peripheral stem cell
from a living donor or an organ transplant bank                transplantation used to support high-dose
and will be charged against the maximum ag-                    chemotherapy when such treatment is Medi-
gregate payment amount.                                        cally Necessary and is not Experimental or
                                                               Investigational;
Special Transplant Benefits                                 7. Pediatric human small bowel transplants;
Benefits are provided for certain procedures,
                                                            8. Pediatric and adult human small bowel and
listed below, only if (1) performed at a Special
                                                               liver transplants in combination;


                                                     -42-
9. Autologous Chondrocyte Implantation/                    2. Licensed vocational nurse;Physical Medi-
   Transplantation.                                           cine, occupational therapy, Speech Therapy
                                                              or respiratory therapy, medical social serv-
Benefits are provided for Services incident to                ices and nutritional counseling provided in
obtaining the transplant material from a living               the home.
donor or an organ transplant bank. Benefits will
be charged against the maximum aggregate                   3. Physical -therapist, occupational therapist,
payment amount.                                               speech therapist or respiratory therapist;
                                                           4. Certified home health aide in conjunction
HOME HEALTH CARE/HOME INFUSION CARE                           with the services of 1, 2 or 3 above;
BENEFITS, AND PKU RELATED FORMULAS
AND SPECIAL FOOD PRODUCTS                                  5. Medical social services provided by a li-
                                                              censed medical social worker for consulta-
Benefits are provided for Services of a Partici-              tion and evaluation and services of a nutri-
pating Home Health Care or Home Infusion                      tional counselor.
agency when medically necessary, ordered by
the attending Physician, and included in a writ-           Note: For information concerning diabetes self-
ten treatment plan, when prior authorized by               management training, see the Diabetes Care
Blue Shield.                                               section.

Benefits are provided only to a Person who is              HOME INFUSION/HOME INJECTABLE THERAPY
home-bound and would otherwise require hos-                BENEFITS
pitalization (except in the case of benefits for
enteral formulas and Special Food Products that            Benefits are provided for home infusion ther-
are Medically Necessary for the treatment of               apy, medical supplies, and pharmaceuticals ad-
phenylketonuria [PKU]). Benefits include visits            ministered intravenously, when medically nec-
for chemotherapy for cancer, catheterization,              essary and prescribed by a Doctor of Medicine.
and associated drugs and supplies.                         All Services must be prior authorized by Blue
                                                           Shield.
Benefits for home health care and home infu-
sion care will be payable up to a maximum                  Certain injectable medications are subject to
benefit of 100 visits for each Person during a             conditions and limitations applicable to other
Calendar Year. For the purpose of this benefit,            benefits of this plan. Insulin, insulin syringes
a visit shall be considered a single visit of any          and certain Home Self-Administered Injectables
length, except for visits from home health aides           are covered under the Outpatient Prescription
for whom a visit of 4 hours or less shall be con-          Drug Benefit.
sidered as one visit.                                      NOTE: Services rendered by Non-
Note: See the Hospice Program Services sec-                Participating Home Health Care and Home
tion for Services provided when a Person is ad-            Infusion Agencies are not covered, unless
mitted into a Hospice Program through a Par-               prior authorized by Blue Shield.
ticipating Hospice Agency.
                                                           PKU RELATED FORMULAS AND SPECIAL FOOD
Intermittent and part-time visits by a home                PRODUCTS
health agency to provide skilled nursing services
                                                           Benefits are provided for enteral formulas and
by any of the following professional providers
                                                           Special Food Products that are Medically Nec-
are payable subject to applicable deductibles
                                                           essary to avert the development of serious
and copayments:
                                                           physical or mental disabilities or to promote
1. Registered nurse;                                       normal development or function as a conse-


                                                    -43-
quence of phenylketonuria (PKU). All benefits              2. Skilled Nursing Services, certified health
must be prior authorized by Blue Shield and                   aide services and homemaker services under
must be prescribed and/or ordered by the appro-               the supervision of a qualified registered
priate health care professional.                              nurse.
Other services: physician, hospital, ambu-                 3. Bereavement Services.
lance, hemodialysis, home medical equipment,
medical supplies, drugs and medicines when                 4. Social Services/Counseling Services with
prescribed and authorized by the attending doc-               medical social services provided by a quali-
tor of medicine, and related pharmaceutical and               fied social worker. Dietary counseling, by a
laboratory services to the extent benefits would              qualified provider, shall also be provided
have been provided had the person remained in                 when needed.
the hospital will be provided as stated under
                                                           5. Medical Direction with the medical director
covered services, and are not subject to the
                                                              being also responsible for meeting the gen-
maximum benefit provided under this section.
                                                              eral medical needs for the Terminal Illness
                                                              of the Person to the extent that these needs
HOSPICE PROGRAM SERVICES                                      are not met by the Person’s other providers.
Benefits are provided for the following Services           6. Volunteer Services.
through a Participating Hospice Agency when
an eligible Person requests admission to and is            7. Short-term Inpatient care arrangements.
formally admitted to an approved Hospice Pro-
gram. The Person must have a Terminal Illness              8. Pharmaceuticals, medical equipment and
as determined by their Physician‘s certification              supplies that are reasonable and necessary
and the admission must receive prior approval                 for the palliation and management of Termi-
from Blue Shield. Covered Services are avail-                 nal Illness and related conditions.
able on a 24-hour basis to the extent necessary            9. Physical therapy, occupational therapy, and
to meet the needs of individuals for care that is             speech-language pathology services for pur-
reasonable and necessary for the palliation and               poses of symptom control, or to enable the
management of Terminal Illness and related                    enrollee to maintain activities of daily living
conditions. Persons can continue to receive cov-              and basic functional skills.
ered Services that are not related to the pallia-
tion and management of the Terminal Illness                10. Nursing care Services are covered on a con-
from the appropriate provider.                                 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 re-                   maintain a Person at home. Hospitalization
ceived through the Participating Hospice                       is covered when the Interdisciplinary Team
Agency. Note: hospice services provided by a                   makes the determination that skilled nursing
Non-Participating hospice agency are not                       care is required at a level that can’t be pro-
covered except in certain circumstances in                     vided in the home. Either Homemaker
counties in California in which there are no                   Services or Home Health Aide Services or
Participating Hospice Agencies and only                        both may be covered on a 24 hour continu-
when prior authorized by Blue Shield.                          ous basis during Periods Of Crisis but the
                                                               care provided during these periods must be
1. Interdisciplinary Team care with develop-
   ment and maintenance of an appropriate                      predominantly nursing care.
   Plan of Care and management of Terminal                 11. Respite Care Services are limited to an oc-
   Illness and related conditions.                             casional basis and to no more than five con-
                                                               secutive days at a time.


                                                    -44-
Persons are allowed to change their Participat-             HOMEMAKER SERVICES – Services that as-
ing Hospice Agency only once during each Pe-                sist in the maintenance of a safe and healthy en-
riod of Care. Persons can receive care for two              vironment and Services to enable the Person to
90-day periods followed by an unlimited num-                carry out the treatment plan.
ber of 60-day periods. The care continues
through another Period of Care if the Partici-              HOSPICE SERVICE OR HOSPICE PRO-
pating Provider recertifies that the Person is              GRAM – a specialized form of interdisciplinary
Terminally ill.                                             health care that is designed to provide palliative
                                                            care, alleviate the physical, emotional, social
DEFINITIONS:                                                and spiritual discomforts of a Person who is ex-
                                                            periencing the last phases of life due to the ex-
BEREAVEMENT SERVICES – Services avail-                      istence of a Terminal Disease, to provide sup-
able to the immediate surviving family members              portive care to the primary caregiver and the
for a period of at least one year after the death           family of the hospice patient, and which meets
of the Person. These Services shall include an              all of the following criteria:
assessment of the needs of the bereaved family
and the development of a care plan that meets               a) Considers the Person and the Person’s fam-
these needs, both prior to, and following the                  ily in addition to the Person, as the unit of
death of the Person.                                           care.

CONTINUOUS HOME CARE – home care                            b) Utilizes an Interdisciplinary Team to assess
provided during a Period of Crisis. A minimum                  the physical, medical, psychological, social
of 8 hours of continuous care, during a 24-hour                and spiritual needs of the Person and their
day, beginning and ending at midnight is re-                   family.
quired. This care could be 4 hours in the morn-
ing and another 4 hours in the evening. Nursing             c) Requires the interdisciplinary team to de-
care must be provided for more than half of the                velop an overall Plan Of Care and to provide
period of care and must be provided by either a                coordinated care which emphasizes suppor-
registered nurse or licensed practical nurse.                  tive Services, including , but not limited to,
Homemaker Services or Home Health Aide                         home care, pain control, and short-term In-
Services may be provided to supplement the                     patient Services. Short-term Inpatient Serv-
nursing care. When fewer than 8 hours of nurs-                 ices are intended to ensure both continuity
ing care are required, the services are covered as             of care and appropriateness of services for
routine home care rather than Continuous Home                  those Persons who cannot be managed at
Care.                                                          home because of acute complications or the
                                                               temporary absence of a capable primary
HOME HEALTH AIDE SERVICES – Services                           caregiver.
providing for the personal care of the Termi-
nally Ill Person and the performance of related             d) Provides for the palliative medical treatment
tasks in the Person’s home in accordance with                  of pain and other symptoms associated with
the Plan Of Care in order to increase the level of             a Terminal Disease, but does not provide for
comfort and to maintain personal hygiene and a                 efforts to cure the disease.
safe, healthy environment for the patient. Home
                                                            e) Provides for Bereavement Services follow-
Health Aide Services shall be provided by a per-
                                                               ing the Person’s death to assist the family to
son who is certified by the state Department of
                                                               cope with social and emotional needs asso-
Health Services as a home health aide pursuant
                                                               ciated with the death.
to Chapter 8 of Division 2 of the Health and
Safety Code.




                                                     -45-
f) Actively utilizes volunteers in the delivery              RESPITE CARE SERVICES – short–term In-
   of Hospice Services.                                      patient care provided to the Person only when
                                                             necessary to relieve the family members or
g) Provides Services in the Person’s home or                 other persons caring for the Person.
   primary place of residence to the extent ap-
   propriate based on the medical needs of the               SKILLED NURSING SERVICES – nursing
   Person.                                                   Services provided by or under the supervision of
                                                             a registered nurse under a Plan of Care devel-
h) Is provided through a Participating Hospice.              oped by the Interdisciplinary Team and the Per-
                                                             son’s provider to the Person and his family that
INTERDISCIPLINARY TEAM – the hospice
                                                             pertain to the palliative, supportive services re-
care team that includes, but is not limited to, the
                                                             quired by the Person with a Terminal Illness.
Person and their family, a physician and sur-
                                                             Skilled Nursing Services include, but are not
geon, a registered nurse, a social worker, a vol-
                                                             limited to, Subscriber or Dependent assessment,
unteer, and a spiritual caregiver.
                                                             evaluation and case management of the medical
MEDICAL DIRECTION – Services provided                        nursing needs of the Person, the performance of
by a licensed physician and surgeon who is                   prescribed medical treatment for pain and
charged with the responsibility of acting as a               symptom control, the provision of emotional
consultant to the Interdisciplinary Team, a con-             support to both the Person and his family, and
sultant to the Person’s Participating Provider, as           the instruction of caregivers in providing per-
requested, with regard to pain and symptom                   sonal care to the enrollee. Skilled Nursing
management, and liaison with physicians and                  Services provide for the continuity of Services
surgeons in the community. For purposes of this              for the Person and his family and are available
section, the person providing these Services                 on a 24-hour on-call basis.
shall be referred to as the “medical director”.
                                                             SOCIAL SERVICE/COUNSELING SERV-
PERIOD OF CARE – the time when the Par-                      ICES - those counseling and spiritual Services
ticipating Provider recertifies that the Person              that assist the Person and his family to minimize
still needs and remains eligible for hospice care            stresses and problems that arise from social,
even if the Person lives longer than one year. A             economic, psychological, or spiritual needs by
Period Of Care starts the day the Person begins              utilizing appropriate community resources, and
to receive hospice care and ends when the 90 or              maximize positive aspects and opportunities for
60- day period has ended.                                    growth.

PERIOD OF CRISIS – a period in which the                     TERMINAL DISEASE OR TERMINAL ILL-
Person requires continuous care to achieve pal-              NESS – a medical condition resulting in a prog-
liation or management of acute medical symp-                 nosis of life of one year or less, if the disease
toms.                                                        follows its natural course.

PLAN OF CARE – a written plan developed by                   VOLUNTEER SERVICES – services provided
the attending physician and surgeon, the “medi-              by trained hospice volunteers who have agreed
cal director” (as defined under “Medical Direc-              to provide service under the direction of a hos-
tion”) or physician and surgeon designee, and                pice staff member who has been designated by
the Interdisciplinary Team that addresses the                the Hospice to provide direction to hospice vol-
needs of a Person and family admitted to the                 unteers. Hospice volunteers may provide sup-
Hospice Program. The Hospice shall retain                    port and companionship to the Person and his
overall responsibility for the development and               family during the remaining days of the Mem-
maintenance of the Plan of Care and quality of               ber’s life and to the surviving family following
Services delivered.                                          the Person’s death.


                                                      -46-
AMBULANCE BENEFITS                                           2. Services other than health care services,
                                                                such as travel, housing, companion expenses
Benefits are provided for (1) Medically Neces-                  and other non-clinical expenses;
sary ambulance services (surface and air) when
used to transport a Person from place of illness             3. Any item or service that is provided solely
or injury to the closest medical facility where                 to satisfy data collection and analysis needs
appropriate treatment can be received, or (2)                   and that is not used in the clinical manage-
Medically Necessary ambulance transportation                    ment of the patient;
from one medical facility to another.
                                                             4. Services that, except for the fact that they
                                                                are being provided in a clinical trial, are
PODIATRIC SERVICES                                              specifically excluded under the Plan;
Benefits are provided for office visits, surgical            5. Services customarily provided by the re-
procedures, and other covered Services custom-                  search sponsor free of charge for any enrol-
arily provided by a licensed doctor of podiatric                lee in the trial.
medicine.
                                                             An approved clinical trial is limited to a trial
CLINICAL TRIAL FOR CANCER                                    that is:

Benefits are provided for routine patient care for           1. Approved by one of the following:
Persons who have been accepted into an ap-
proved clinical trial for cancer when prior                     a. one of the National Institutes of Health;
authorized by Blue Shield, and:                                 b. the federal Food and Drug Administra-
1. the clinical trial has a therapeutic intent and                 tion, in the form of an investigational
   the Person’s treating Physician determines                      new drug application;
   that participation in the clinical trial has a
                                                                c. the United States Department of De-
   meaningful potential to benefit the Person
                                                                   fense;
   with a therapeutic intent and;
2. the Person’s treating Physician recommends                   d. the United States Veterans’ Administra-
   participation in the clinical trial; and                        tion; or

3. the Hospital and/or Physician conducting the              2. Involves a drug that is exempt under federal
   clinical trial is a Participating Provider, un-              regulations from a new drug application.
   less the protocol for the trial is not available
   through a Participating Provider.                         WELL BABY CARE BENEFITS
Services for routine patient care will be paid on            Benefits are provided for Services of a Physi-
the same basis and at the same benefit levels as             cian for a newborn or Dependent child less than
other covered Services shown in the Summary                  three years of age of the Subscriber or the cov-
of Benefits.                                                 ered spouse, including:
Routine patient care consists of those Services              1. routine newborn care in the Hospital in-
that would otherwise be covered by the Plan if                  cluding physical examination of the baby
those Services were not provided in connection                  and counseling with the mother concerning
with an approved clinical trial, but does not in-               the baby during the Hospital stay;
clude:
                                                             2. office visits;
1. Drugs or devices that have not been ap-
   proved by the federal Food and Drug Ad-                   3. tuberculin tests;
   ministration (FDA);

                                                      -47-
4. immunizations and the immunizing agent, as                   c. surgically implanted hearing devices.
   recommended by the American Academy of
   Pediatrics and the United States Public                   MENTAL HEALTH AND SUBSTANCE
   Health Service through its U. S. Preventive
                                                             ABUSE BENEFITS
   Services Task Force and/or the Advisory
   Committee on Immunization Practices                       Your employer has made arrangements for cov-
   (ACIP) of the Centers for Disease Control                 erage of mental health services as required by
   (CDC).                                                    state law and any covered substance abuse
   No benefits are provided for routine cir-                 services through a separate health plan. Please
   cumcision.                                                contact your employer for instructions on how
                                                             to obtain these services. If for any reason, the
HEARING AID SERVICES                                         arrangement with that other health plan is ter-
                                                             minated or the other plan fails to provide the
1. Benefits are provided for Audiological                    minimum mental health coverage as required by
   Evaluation to measure the extent of hearing               California law, your employers' group health
   loss and a hearing aid evaluation to deter-               service contract with Blue Shield of California
   mine the most appropriate make and model                  will be automatically amended to provide cov-
   of hearing aid.                                           erage for these services. In that event, you will
   Evaluation is in addition to the $1,000.00                receive notification and an insert to your Evi-
   maximum payment every 36 months for the                   dence of Coverage booklet that will provide the
   hearing aid and ancillary equipment.                      benefits as required by law.
2. Benefits are provided for Hearing Aid, mon-
   aural or binaural including ear mold(s), the              SUBSTANCE ABUSE BENEFITS
   hearing aid instrument, the initial battery,              (For Acute Conditions)
   cords and other ancillary equipment. Bene-                Benefits are provided for Inpatient treatment of
   fits include visits for fitting, counseling, ad-          substance abuse detoxification rendered in a
   justments, repairs, etc. at no charge for a               Hospital when confinement is certified by the
   one-year period following the provision of a              attending Physician as medically necessary by
   covered hearing aid.                                      reason of the Person's acute condition. (Note:
2. Benefits are limited to a maximum of                      for Subscriber copayments for Medically Nec-
   $1,000.00 per Person every 36 months for                  essary Inpatient substance abuse detoxification,
   the hearing aid instrument, and ancillary                 see Hospital Benefits, Inpatient Services for
   equipment.                                                Treatment of Illness or Injury.)

3. The following services and supplies are ex-
   cluded:                                                   PRINCIPAL LIMITATIONS, EXCEPTIONS,
   a. purchase of batteries or other ancillary
                                                             EXCLUSIONS AND REDUCTIONS
      equipment, except those covered under
      the terms of the initial hearing aid pur-              GENERAL EXCLUSIONS
      chase and charges for a hearing aid
      which exceed specifications prescribed                 Unless exceptions to the following are specifi-
      for correction of a hearing loss;                      cally made elsewhere in this booklet, no bene-
                                                             fits are provided for services:
   b. replacement parts for hearing aids, repair
      of hearing aid after the covered one-year              1. for or incident to hospitalization or con-
      warranty period and replacement of a                      finement in a pain management center to
      hearing aid more than once in any period                  treat or cure chronic pain, except as may
      of 36 months;                                             be provided through a Participating Hos-

                                                      -48-
   pice Agency and except as Medically Nec-                 ARRANGEMENT YOUR EMPLOYER
   essary;                                                  HAS   MADE   WITH   ANOTHER
                                                            HEALTH PLAN TO PROVIDE THESE
2. for Rehabilitation or Rehabilitative Care,               BENEFITS);
   except for Services for which benefits
   have been expressly pre-approved under                8. for hearing aids, except as specifically
   the Benefits Management Program, when                    provided;
   services are the result of the following
   conditions: psychosocial speech delay in-             9. for routine eye refractions;
   cluding delayed language development,
                                                         10. for eyeglasses, contact lenses or surgery
   mental retardation or dyslexia, syn-
                                                             for refractive error (e.g. radial keratot-
   dromes associated with diagnosed disor-
                                                             omy), except as specifically listed;
   ders attributed to perceptual and concep-
   tual dysfunctions, and developmental                  11. for any type of communicator, voice en-
   articulation and language disorders;                      hancer, voice prosthesis or any other lan-
                                                             guage assistive devices, except as specifi-
3. for or incident to services rendered in the
                                                             cally listed under Prosthetic Appliances
   home or hospitalization or confinement in
                                                             and Home Medical Equipment Benefits;
   a health facility primarily for rest, Custo-
   dial, Maintenance or Domiciliary Care,                12. for routine physical examinations, except
   except as provided under the Hospice                      as specifically listed under Preventive
   Program Services (see the Hospice Pro-                    Care Benefits or for examinations re-
   gram Services benefit for exception);                     quired for licensure, employment, or in-
                                                             surance unless the examination is substi-
4. performed in a Hospital by house officers,                tuted for the Annual Health Appraisal
   residents, interns and others in training;
                                                             Exam;
5. performed by a Close Relative or by a
                                                         13. for or incident to acupuncture, except as
   person who ordinarily resides in the cov-
                                                             specifically listed;
   ered Person's home;
                                                         14. for or incident to Speech Therapy, except
6. for substance abuse care or rehabilitation
                                                             as specifically listed under Speech Ther-
   on an Inpatient or Outpatient basis ex-
                                                             apy Benefits;
   cept for the Inpatient treatment of sub-
   stance abuse when confinement is certi-               15. for drugs and medicines which cannot be
   fied by     the attending Physician as                    lawfully marketed without approval of
   medically necessary by reason of the Per-                 the U.S. Food and Drug Administration
   son's acute condition (SEE THE SEC-                       (the FDA); however, drugs and medicines
   TION ENTITLED "MENTAL HEALTH                              which have received FDA approval for
   AND SUBSTANCE ABUSE BENEFITS"                             marketing for one or more uses will not
   FOR INFORMATION REGARDING                                 be denied on the basis that they are being
   THE ARRANGEMENT YOUR EM-                                  prescribed for an off-label use if the con-
   PLOYER HAS MADE WITH AN-                                  ditions set forth in California Health &
   OTHER HEALTH PLAN TO PROVIDE                              Safety Code, Section 1367.21 have been
   THESE BENEFITS);                                          met;
7. for Mental Health (SEE THE SECTION                    16. for or incident to vocational, educational,
   ENTITLED" MENTAL HEALTH AND                               recreational, art, dance, music or reading
   SUBSTANCE ABUSE BENEFITS" FOR                             therapy; weight control programs; or ex-
   INFORMATION REGARDING THE                                 ercise programs;


                                                  -49-
17. for or incident to intersex surgery (trans-               agnostic, preventive, periodontic and or-
    sexual operations), or any resulting medi-                thodontic services; dental implants;
    cal complications, except for treatment of                braces, crowns, dental orthoses and pros-
    medical complications that is medically                   theses; except as specifically provided un-
    necessary;                                                der Medical Treatment of Teeth, Gums,
                                                              Jaw Joints or Jaw Bones Benefits and
18. for sexual dysfunctions and sexual inade-                 Hospital Benefits;
    quacies, except as provided for treatment
    of organically based conditions;                       26. incident to organ transplant, except as
                                                               explicitly listed under the Organ Trans-
19. for or incident to Infertility, including but              plant Benefit and Special Transplant
    not limited to reversal of surgical sterili-               Benefit;
    zation, in vitro fertilization, or complica-
    tions of any such procedures;                          27. for Cosmetic Surgery or any resulting
                                                               complications, except that benefits are
20. for callus, corn paring or excision and                    provided for medically necessary Services
    toenail trimming except as may be pro-                     to treat complications of cosmetic surgery
    vided through a Participating Hospice                      (e.g., infections or hemorrhages), when
    Agency; treatment (other than surgery) of                  reviewed and approved by a Blue Shield
    chronic conditions of the foot, e.g., weak                 of California consultant. No benefits will
    or fallen arches; flat or pronated foot;                   be provided for reimplantation of breast
    pain or cramp of the foot; for special                     implants originally provided for cosmetic
    footwear required for foot disfigurement,                  augmentation;
    except as specifically listed under Ortho-
    ses Benefits and Diabetes Care; bunions;               28. for Reconstructive Surgery, and proce-
    or muscle trauma due to exertion; or any                   dures in situations: 1) where there is an-
    type of massage procedure on the foot;                     other more appropriate surgical proce-
                                                               dure that is approved by a Blue Shield
21. which are Experimental or Investiga-                       physician consultant, or 2) when the sur-
    tional in nature, except for Services for                  gery or procedure offers only a minimal
    Persons who have been accepted into an                     improvement in function or in the ap-
    approved clinical trial for cancer as pro-                 pearance of the enrollees, e.g., spider
    vided under Clinical Trial for Cancer;                     veins;
22. for the treatment of learning disabilities             29. for penile implant devices and surgery,
    or behavioral problems;                                    and any related services, except for any
                                                               resulting complications and medically
23. hospitalization primarily for X-ray, labo-
                                                               necessary Services;
    ratory or any other diagnostic studies or
    medical observation;                                   30. in connection with the treatment of a Pre-
                                                               existing Condition, except as specifically
24. for dental care or Services incident to the
                                                               listed;
    treatment, prevention or relief of pain or
    dysfunction of the Temporomandibular                   31. for patient convenience items such as
    Joint and/or muscles of mastication, ex-                   telephone, television, guest trays, and per-
    cept as specifically provided under the                    sonal hygiene items;
    Medical Treatment of Teeth, Gums, Jaw
    Joints or Jawbones and Hospital Benefits;              32. for which the Person is not legally obli-
                                                               gated to pay, or for Services for which no
25. for or incident to dental care and dental                  charge is made;
    supplies including but not limited to di-

                                                    -50-
33. incident to any injury or disease arising              MEDICAL NECESSITY EXCLUSION
    out of, or in the course of, any employ-
    ment for salary, wage or profit if such in-            The benefits of this plan are intended only
    jury or disease is covered by any worker's             for Services that are medically necessary.
    compensation law, occupational disease                 Because a Physician or other provider may
    law or similar legislation. However, if                prescribe, order, recommend, or approve a
    Blue Shield of California provides pay-                service or supply does not, in itself, make it
    ment for such Services, it will be entitled            medically necessary even though it is not spe-
    to establish a lien upon such other bene-              cifically listed as an exclusion or limitation.
    fits up to the amount paid by Blue Shield              Blue Shield of California reserves the right to
    of California for the treatment of such in-            review all claims to determine if a service or
    jury or disease;                                       supply is medically necessary. Blue Shield of
                                                           California may use the Services of Doctor of
34. in connection with private duty nursing,               Medicine consultants, peer review commit-
    except as provided under the Home                      tees of professional societies or Hospitals and
    Health Care, Home Infusion Care Bene-                  other consultants to evaluate claims. Blue
    fits and PKU Related Formulas and Spe-                 Shield of California may limit or exclude
    cial Food Products covered Services and                benefits for Services which are not necessary.
    except as provided through a Participat-
    ing Hospice Agency;
                                                           PRE-EXISTING CONDITIONS
35. for prescription and non-prescription
                                                           Pre-existing Conditions are covered immedi-
    food and nutritional supplements, except
                                                           ately if you were validly covered under your
    as provided under the Home Health Care,
                                                           present employer's previous group health plan
    Home Infusion Care Benefits, and PKU
                                                           when that plan was terminated and are enrolled
    Related Formulas and Special Food
                                                           on the original effective date of this plan within
    Products benefit and except as provided
                                                           60 days of the termination of that previous plan,
    through a Participating Hospice Agency;
                                                           except that:
36. for home testing devices and monitoring
                                                           If you or your Dependents were enrolled in the
    equipment except for use of the peak flow
                                                           previous group health plan for less than 6
    monitor for self-management of asthma,
                                                           months and were Totally Disabled on the date of
    the glucose monitor for self-management
                                                           discontinuance of the previous group health plan
    of diabetes and the apnea monitor for
                                                           and were entitled to an extension of benefits un-
    management of newborn’s apnea when
                                                           der Section 1399.62 of the California Health and
    authorized as home medical equipment;
                                                           Safety Code or Section 10128.2 of the Califor-
37. for contraceptives and contraceptive de-               nia Insurance Code, you or your Dependents
    vices, except as specifically included in the          will not be entitled to any benefits under this
    Family Planning Services benefit; oral                 plan for Services or expenses directly related to
    contraceptives and diaphragms are ex-                  any condition which caused such Total Disabil-
    cluded; no benefits are provided for con-              ity for a period not to exceed 6 months. Blue
    traceptive implants.                                   Shield will credit the time you or your Depend-
                                                           ents were covered under the prior Creditable
38. for Outpatient prescription drugs.                     Coverage toward this plan’s Pre-existing Con-
                                                           dition exclusion.
See the Grievance Process for information on
filing a grievance, your right to seek                     If you or any Dependent was not validly cov-
assistance from the Department of Managed                  ered under your present employer's previous
Health Care, and your rights to independent                group health plan, then coverage under this plan
medical review                                             is provided for Pre-existing Conditions only af-

                                                    -51-
ter you have been continuously covered for 6                This exclusion is applicable to benefits received
consecutive months, including your present em-              from any of the following sources:
ployer's waiting period, if any.
                                                            1. Benefits provided under Title XVIII of the
However, if you or your Dependents had prior                   Social Security Act (commonly known as
Creditable Coverage and you enrolled in this                   Medicare). If a covered Person receives
plan within 63 days after termination (exclusive               Services for which he is entitled to benefits
of any waiting period) of the prior Creditable                 under Medicare and those Services are also
Coverage or within 180 days (exclusive of the                  covered under this plan, the benefits of this
waiting period) if your prior Creditable Cover-                plan will be provided less the amount paid
age was Employer-sponsored, then Blue Shield                   under Medicare. Any deductible or copay-
will credit the time you or your Dependents                    ment requirement of this plan will be waived
were covered under the prior Creditable Cover-                 when Medicare is primary and the provider
age toward this plan's Pre-existing Condition                  of Services has accepted Medicare assign-
exclusion.                                                     ment. This exclusion for Medicare does not
                                                               apply when the Employer is subject to the
To receive credit for your prior Creditable Cov-               Medicare Secondary Payer laws and the
erage, submit to Blue Shield a certificate from                Employer maintains:
your prior employer, insurer, or health plan
which shows the period of time you were cov-                   a. an employer group health plan that cov-
ered under the prior Creditable Coverage. If                      ers Persons entitled to Medicare solely
you are unable to obtain the certificate, you                     because of end-stage renal disease and
should contact Blue Shield of California's Cus-                   active Employees or spouses entitled to
tomer Service area for assistance.                                Medicare by reason of age; and/or

This plan's Pre-existing Condition exclusion                   b. a large group health plan as defined un-
does not apply to:                                                der the Medicare Secondary Payer laws
                                                                  that covers Persons entitled to Medicare
1. pregnancy benefits;                                            by reason of disability.

2. newborns or children placed for adoption                    This paragraph shall also apply to an indi-
   who had prior Creditable Coverage within                    vidual who becomes eligible for Medicare
   30 days of the birth or placement for adop-                 benefits prior to age 65, but who had not en-
   tion, who enrolled in this plan within 63                   rolled under Medicare on the date that he re-
   days of that prior Creditable Coverage (ex-                 ceived notice from Blue Shield of California
   clusive of any waiting period).                             of eligibility for such enrollment.
                                                            2. Any Services, including room and board,
EXCLUSION FOR DUPLICATE COVERAGE                               provided by any other Federal or State gov-
                                                               ernmental agency, or by any Municipality,
In the event that you are covered under this plan
                                                               County or other political subdivision except
and are also entitled to benefits under any of the
                                                               that this exclusion does not apply to the
conditions listed below, Blue Shield's liability
                                                               Medi-Cal program, or Subchapter 19 (com-
for Services (including room and board) pro-
                                                               mencing with Section 1396) of Chapter 7 of
vided for the treatment of any one illness or in-
                                                               Title 42 of the United States Code or for
jury will be reduced by the amount of benefits
                                                               reasonable costs of Services provided to the
paid, or the reasonable value or the amount of
                                                               Person at a Veterans' Administration facility
Blue Shield’s fee-for-service payment to the
                                                               for a condition unrelated to military Service
provider, whichever is less, of the Services or
                                                               or at a Department of Defense facility, pro-
supplies provided without any cost to you, be-
                                                               vided the Person is not on active duty.
cause of your entitlement to such other benefits.


                                                     -52-
EXCEPTION FOR OTHER COVERAGE                                   vided, calculated in accordance with Cali-
                                                               fornia Civil Code section 3040. The lien
Participating Providers and Preferred Providers                may be filed with the third party, the third
may seek reimbursement from other third party                  party's agent or attorney, or the court, unless
payers for the balance of their reasonable                     otherwise prohibited by law.
charges for Services rendered under this plan.
                                                            A covered Person’s failure to comply with 1
                                                            through 3, above, shall not in any way act as a
CLAIMS REVIEW
                                                            waiver, release, or relinquishment of the rights
Blue Shield of California reserves the right to             of Blue Shield.
review all claims to determine if any exclusions
or other limitations apply. Blue Shield of Cali-            GENERAL PROVISIONS
fornia may use the Services of Physician con-
sultants, peer review committees of professional
societies or Hospitals and other consultants to             COORDINATION OF BENEFITS
evaluate claims.
                                                            When a Person who is covered under this group
                                                            plan is also covered under another group plan,
REDUCTIONS                                                  or selected group, or blanket disability insurance
                                                            contract, or any other contractual arrangement
Third-Party Liability — If a covered Person is              or any portion of any such arrangement whereby
injured through the act or omission of another              the members of a group are entitled to payment
person (a “third party”), Blue Shield of Califor-           of or reimbursement for Hospital or medical ex-
nia shall, with respect to Services required as a           penses, such Person will not be permitted to
result of that injury, provide the benefits of the          make a “profit” on a disability by collecting
plan and have an equitable right to restitution or          benefits in excess of actual cost during any Cal-
other available remedy to recover the reasonable            endar Year. Instead, payments will be coordi-
costs of the Services provided to the covered               nated between the plans in order to provide for
Person paid by Blue Shield on a fee-for-service             “allowable expenses” (these are the expenses
basis.                                                      that are Incurred for Services and supplies cov-
The covered Person is required to:                          ered under at least one of the plans involved) up
                                                            to the maximum benefit amount payable by
1. Notify Blue Shield in writing of any actual              each plan separately.
   or potential claim or legal action which such
   covered Person anticipates bringing or has               If the covered Person is also entitled to benefits
   brought against the third party arising from             under any of the conditions as outlined under
   the alleged acts or omissions causing the                the “Exclusion for Duplicate Coverage” provi-
   injury or illness, not later than 30 days after          sion, benefits received under any such condition
   submitting or filing a claim or legal action             will not be coordinated with the benefits of this
   against the third party; and                             plan.

2. Agree to fully cooperate with Blue Shield to             The following rules determine the order of
   execute any forms or documents needed to                 benefit payments:
   assist them in exercising their equitable right          When the other plan does not have a coordina-
   to restitution or other available remedies;              tion of benefits provision it will always provide
   and                                                      its benefits first. Otherwise, the plan covering
3. Provide Blue Shield with a lien, in the                  the Person as an Employee will provide its
   amount of reasonable costs of benefits pro-              benefits before the plan covering the Person as a
                                                            Dependent.


                                                     -53-
The plan which covers the Person as a Depend-                  b. if either plan does not have a provision
ent of a Person whose date of birth, (excluding                   regarding laid-off or retired Employees,
year of birth), occurs earlier in a Calendar Year,                which results in each plan determining
will determine its benefits before a plan which                   its benefits after the other, then para-
covers that Person as a Dependent of a Person                     graph (a.) above will not apply.
whose date of birth, (excluding year of birth),
occurs later in a Calendar Year. If either plan             If this plan is the primary carrier in the case of a
does not have the provisions of this paragraph              covered Person, then this plan will provide its
regarding Dependents, which results either in               benefits without making any reduction because
each plan determining its benefits before the               of benefits available from any other plan, except
other or in each plan determining its benefits              that Physician Members and other Participating
after the other, the provisions of this paragraph           Providers may collect any difference between
will not apply, and the rule set forth in the plan          their Billed Charges and this plan's payment,
which does not have the provisions of this para-            from the secondary carrier(s).
graph will determine the order of benefits.
                                                            If this plan is the secondary carrier in the order
1. In the case of a claim involving expenses for            of payments, and Blue Shield of California is
   a dependent child whose parents are sepa-                notified that there is a dispute as to which plan
   rated or divorced, plans covering the child as           is primary, or that the primary plan has not paid
   a Dependent will determine their respective              within a reasonable period of time, this plan will
   benefits in the following order:                         pay the benefits that would be due as if it were
                                                            the primary plan, provided that the covered Per-
   First, the plan of the parent with custody of            son (1) assigns to Blue Shield of California the
   the child; then, if that parent has remarried,           right to receive benefits from the other plan to
   the plan of the stepparent with custody of               the extent of the difference between the benefits
   the child; and finally the plan(s) of the par-           which Blue Shield of California actually pays
   ent(s) without custody of the child.                     and the amount that Blue Shield of California
                                                            would have been obligated to pay as the secon-
2. Regardless of (1.) above, if there is a court
                                                            dary plan, (2) agrees to cooperate fully with
   decree which otherwise establishes financial
                                                            Blue Shield of California in obtaining payment
   responsibility for the medical, dental or
                                                            of benefits from the other plan, and (3) allows
   other health care expenses of the child, then
                                                            Blue Shield of California to obtain confirmation
   the plan which covers the child as a De-
                                                            from the other plan that the benefits which are
   pendent of that parent will determine its
                                                            claimed have not previously been paid.
   benefits before any other plan which covers
   the child as a dependent child.                          If payments which should have been made un-
                                                            der this plan in accordance with these provisions
3. If the above rules do not apply, the plan                have been made by another plan, Blue Shield
   which has covered the Person for the longer              may pay to the other plan the amount necessary
   period of time will determine its benefits               to satisfy the intent of these provisions. This
   first, provided that:                                    amount shall be considered as benefits paid un-
                                                            der this plan. Blue Shield shall be fully dis-
   a. a plan covering a Person as a laid-off or
                                                            charged from liability under this plan to the ex-
      retired Employee, or as a Dependent of
                                                            tent of these payments.
      that Person will determine its benefits
      after any other plan covering that Person             If payments have been made by Blue Shield in
      as an Employee, other than a laid-off or              excess of the maximum amount of payment
      retired Employee, or such Dependent;                  necessary to satisfy these provisions, Blue
      and                                                   Shield shall have the right to recover the excess


                                                     -54-
from any person or other entity to or with re-              son is entitled to benefits if at the time of the
spect to whom such payments were made.                      qualifying event such Person is entitled to
                                                            Medicare. However, if Medicare entitlement
Blue Shield may release to or obtain from any               arises after COBRA coverage begins, it will
organization or person any information which                cease.
Blue Shield considers necessary for the purpose
of determining the applicability of and imple-              Qualifying Event
menting the terms of these provisions or any
provisions of similar purpose of any other plan.            A Qualifying Event is defined as a loss of cov-
Any person claiming benefits under this plan                erage as a result of any one of the following oc-
shall furnish Blue Shield with such information             currences.
as may be necessary to implement these provi-
sions.                                                      1. With respect to the Subscriber:
                                                               a. the termination of employment (other
CONTINUATION OF GROUP COVERAGE                                    than by reason of gross misconduct); or
Applicable to Persons when the Subscriber’s                    b. the reduction of hours of employment to
Employer (Contractholder) is subject to ei-                       less than the number of hours required
ther Title X of the Consolidated Omnibus                          for eligibility.
Budget Reconciliation Act (COBRA) as
amended or the California Continuation                      2. With respect to the Dependent spouse and
Benefits Replacement Act (Cal-COBRA).                          Dependent children (children born to or
The Subscriber’s Employer should be con-                       placed for adoption with the Subscriber
tacted for more information.                                   during a COBRA or Cal-COBRA continua-
                                                               tion period may be immediately added as
In accordance with the Consolidated Omnibus                    Dependents, provided the Contractholder is
Budget Reconciliation Act (COBRA) as                           properly notified of the birth or placement
amended and the California Continuation Bene-                  for adoption, and such children are enrolled
fits Replacement Act (Cal-COBRA), a Person                     within 30 days of the birth or placement for
will be entitled to elect to continue group cover-             adoption):
age under this plan if the Person would other-
wise lose coverage because of a Qualifying                     a. the death of the Subscriber; or
Event that occurs while the contract holder is                 b. the termination of the Subscriber’s em-
subject to the continuation of group coverage                     ployment (other than by reason of such
provisions of COBRA or Cal-COBRA. The                             Subscriber’s gross misconduct); or
benefits under the group continuation of cover-
age will be identical to the benefits that would               c. the reduction of the Subscriber’s hours
be provided to the Person if the Qualifying                       of employment to less than the number
Event had not occurred (including any changes                     of hours required for eligibility; or
in such coverage).
                                                               d. the divorce or legal separation of the
Note: A Person will not be entitled to benefits                   Subscriber from the Dependent spouse;
under Cal-COBRA if at the time of the qualify-                    or
ing event such Person is entitled to benefits un-
der Title XVIII of the Social Security Act                     e. the Subscriber’s entitlement to benefits
(“Medicare”) or is covered under another                          under Title XVIII of the Social Security
group health plan that provides coverage with-                    Act (“Medicare”); or
out exclusions or limitations with respect to any              f. a Dependent child’s loss of Dependent
Pre-existing condition. Under COBRA, a Per-                       status under this plan.


                                                     -55-
3. For COBRA only, with respect to a Sub-                 2. With respect to Cal-COBRA enrollees:
   scriber who is covered as a retiree, that re-
   tiree’s Dependent spouse and Dependent                    The Person is responsible for notifying Blue
   children, the Employer's filing for reorgani-             Shield in writing of the Subscriber’s death
   zation under Title XI, United States Code,                or Medicare entitlement, of divorce, legal
   commencing on or after July 1, 1986.                      separation or a child’s loss of Dependent
                                                             status under this plan. Such notice must be
4. With respect to any of the above, such other              given within 60 days of the date of the later
   Qualifying Event as may be added to Title X               of the Qualifying Event or the date on which
   of COBRA or the California Continuation                   coverage would otherwise terminate under
   Benefits Replacement Act (Cal-COBRA).                     this plan because of a Qualifying Event.
                                                             Failure to provide such notice within 60
Notification of a Qualifying Event                           days will disqualify the Person from receiv-
                                                             ing continuation coverage under Cal-
1. With respect to COBRA enrollees:                          COBRA.
   The Person is responsible for notifying the               The Employer is responsible for notifying
   Employer of divorce, legal separation or a                Blue Shield in writing of the Subscriber’s
   child’s loss of Dependent status under this               termination or reduction of hours of em-
   plan, within 60 days of the date of the later             ployment within 30 days of the Qualifying
   of the Qualifying Event or the date on which              Event.
   coverage would otherwise terminate under
   this plan because of a Qualifying Event.                  When Blue Shield is notified that a Quali-
                                                             fying Event has occurred, Blue Shield will
   The Employer is responsible for notifying its             inform the Person within 14 days of the Per-
   COBRA administrator (or plan administrator                son’s right to continue group coverage under
   if the Employer does not have a COBRA                     this plan. The Person must then give Blue
   administrator) of the Subscriber’s death,                 Shield notice in writing of the Person’s
   termination or reduction of hours of em-                  election of continuation coverage within 60
   ployment, the Subscriber’s Medicare enti-                 days of the later of (1) the date of the notice
   tlement or the Employer’s filing for reor-                of the Person’s right to continue group cov-
   ganization under Title XI, United States                  erage or (2) the date coverage terminates
   Code.                                                     due to the Qualifying Event. The written
                                                             election notice must be delivered to Blue
   When the COBRA administrator is notified
                                                             Shield by first-class mail or other reliable
   that a Qualifying Event has occurred, the
                                                             means.
   COBRA administrator will inform the Per-
   son within 14 days of the Person’s right to               If the Person does not notify Blue Shield
   continue group coverage under this plan.                  within 60 days, the Person’s coverage will
   The Person must then notify the COBRA                     terminate on the date the Person would
   administrator within 60 days of the later of              have lost coverage because of the Quali-
   (1) the date of the notice of the Person’s                fying Event.
   right to continue group coverage or (2) the
   date coverage terminates due to the Quali-                If this plan replaces a previous group plan
   fying Event.                                              that was in effect with the Employer, and the
                                                             Person had elected Cal-COBRA continua-
   If the Person does not notify the COBRA                   tion coverage under the previous plan, the
   administrator within 60 days, the Per-                    Person may choose to continue to be cov-
   son’s coverage will terminate on the date                 ered by this plan for the balance of the pe-
   the Person would have lost coverage be-                   riod that the Person could have continued to
   cause of the Qualifying Event.

                                                   -56-
   be covered under the previous plan, pro-                period. The Person is responsible for notifying
   vided that the Person notify Blue Shield                Blue Shield within 30 days of any final determi-
   within 30 days of receiving notice of the               nation that he or she is no longer disabled.
   termination of the previous group plan.
                                                           For COBRA and Cal-COBRA enrollees who
Duration and Extension                                     became eligible for COBRA or Cal-COBRA
                                                           coverage on or after January 1, 2003:
of Continuation of Group Coverage
                                                           Cal-COBRA enrollees who became eligible for
For COBRA or Cal-COBRA enrollees who
                                                           Cal-COBRA coverage on or after January 1,
became eligible for COBRA or Cal-COBRA
                                                           2003, will be eligible to continue Cal-COBRA
prior to January 1, 2003:
                                                           coverage under this plan for up to a maximum
The Person will be entitled to continue group              of 36 months regardless of the type of Qualify-
coverage under this plan up to a maximum of 36             ing Event.
months, except when the Subscriber has lost
                                                           COBRA enrollees who became eligible for
coverage because of termination or reduction of
                                                           COBRA coverage on or after January 1, 2003,
work hours required for eligibility. For these
                                                           and who reach the 18-month or 29-month
Subscribers and their Dependents, group cover-
                                                           maximum available under COBRA, may elect
age may only be continued for a maximum of
                                                           to continue coverage under Cal-COBRA for a
18 months. This 18-month period may be ex-
                                                           maximum period of 36 months from the date the
tended to 36 months if a second Qualifying
                                                           Person’s continuation coverage began under
Event such as death, divorce, legal separation,
                                                           COBRA. If elected, the Cal-COBRA coverage
loss of dependent status or Medicare entitlement
                                                           will begin after the COBRA coverage ends.
occurs during the first 18-month period.
                                                           Note: COBRA enrollees must exhaust all the
The Person’s 18-month period may also be ex-
                                                           COBRA coverage to which they are entitled
tended to 29 months if under the Social Security
                                                           before they can become eligible to continue
Act the Person was determined to be disabled on
                                                           coverage under Cal-COBRA.
or before the date of termination or reduction in
hours of employment, or is determined to be                In no event will continuation of group coverage
disabled under the Social Security Act within              under COBRA, Cal-COBRA or a combination
the first 60 days of the initial Qualifying Event          of COBRA and Cal-COBRA be extended for
and notification is given to the Employer or               more than 3 years from the date the Qualifying
Blue Shield as indicated below before the end of           Event has occurred which originally entitled the
the 18-month period (non-disabled eligible                 Person to continue group coverage under this
family members are also entitled to this 29-               plan. However, a Person may qualify for con-
month extension).                                          tinuation of group coverage after COBRA
                                                           and/or Cal-COBRA. This coverage is explained
For COBRA enrollees: The Employer must be
                                                           under Continuation of Group Coverage After
notified of the Social Security Act determination
                                                           COBRA and/or Cal-COBRA.
within 60 days of the date of the determination
letter and before the end of the 18-month period.
The Person is responsible for notifying the Em-            Notification Requirements
ployer within 30 days of any final determination           The Employer or its COBRA administrator is
that he or she is no longer disabled.                      responsible for notifying COBRA enrollees of
For Cal-COBRA enrollees: Blue Shield must                  their right to possibly continue coverage under
be notified of the Social Security Act determi-            Cal-COBRA at least 90 calendar days before
nation within 60 days of the date of the determi-          their COBRA coverage will end. The COBRA
nation letter and before the end of the 18-month           enrollee should contact Blue Shield for more in-


                                                    -57-
formation about continuing coverage. If the en-             Effective Date
rollee elects to apply for continuation of cover-           of the Continuation of Coverage
age under Cal-COBRA, the enrollee must notify
Blue Shield at least 30 days before COBRA                   The continuation of coverage will begin on the
termination.                                                date the Person’s coverage under this plan
                                                            would otherwise terminate due to the occurrence
Payment of Dues                                             of a Qualifying Event and it will continue for up
                                                            to the applicable period, provided that coverage
Dues for the Person continuing coverage shall               is timely elected and so long as dues are timely
be 102 percent of the applicable group dues rate            paid.
if the Person is a COBRA enrollee, or 110 per-
cent of the applicable group dues rate if the Per-          Termination
son is a Cal-COBRA enrollee, except for the                 of Continuation of Group Coverage
Person who is eligible to continue group cover-
age to 29 months because of a Social Security               The continuation of group coverage will cease if
disability determination, in which case, the dues           any one of the following events occurs prior to
for months 19 through 29 shall be 150 percent               the expiration of the applicable period of con-
of the applicable group dues rate.                          tinuation of group coverage:
                                                            1. discontinuance of this group health service
Note: For COBRA enrollees who became eligi-
                                                               contract (if the Employer continues to pro-
ble for COBRA coverage on or after January 1,
                                                               vide any group benefit plan for employees,
2003, and who are eligible to extend group cov-
                                                               the Person may be able to continue coverage
erage under COBRA to 29 months because of a
                                                               with another plan);
Social Security disability determination, dues
for Cal-COBRA coverage shall be 110 percent                 2. failure to timely and fully pay the amount of
of the applicable group dues rate for months 30                required dues to the COBRA administrator
through 36.                                                    or the Employer or to Blue Shield of Cali-
                                                               fornia as applicable. Coverage will end as of
If the Person is enrolled in COBRA and is con-                 the end of the period for which dues were
tributing to the cost of coverage, the Employer                paid;
shall be responsible for collecting and submit-
ting all dues contributions to Blue Shield of               3. the Person becomes covered under another
California in the manner and for the period es-                group health plan that does not include a
tablished under this plan.                                     Pre-existing Condition exclusion or limita-
                                                               tion provision that applies to the Person;
Cal-COBRA enrollees must submit dues di-
rectly to Blue Shield of California. The initial            4. the Person becomes entitled to Medicare;
dues must be paid within 45 days of the date the            5. the Person no longer resides in Blue Shield’s
Person provided written notification to the plan               service area;
of the election to continue coverage and be sent
to Blue Shield by first-class mail or other reli-           6. the Person commits fraud or deception in the
able means. The dues payment must equal an                     use of the Services of this plan.
amount sufficient to pay any required amounts
                                                            Continuation of group coverage in accordance
that are due. Failure to submit the correct
                                                            with COBRA or Cal-COBRA will not be termi-
amount within the 45-day period will disqualify
                                                            nated except as described in this provision. In
the Person from continuation coverage.
                                                            no event will coverage extend beyond 36
                                                            months.




                                                     -58-
CONTINUATION OF GROUP COVERAGE                            or 102 percent of the applicable age adjusted
AFTER COBRA AND/OR CAL-COBRA                              group dues rate. For Persons who transfer to
                                                          this coverage from Cal-COBRA, dues for this
Certain former Employees and their Dependent              coverage shall be 213 percent of the applica-
spouses (including a spouse who is divorced               ble group dues rate, or 110 percent of the ap-
from the current Employee/former Employee                 plicable age adjusted group dues rate. Pay-
and/or a spouse who was married to the Em-                ment is due at the time the Employer’s
ployee/former Employee at the time of that Em-            payment is due.
ployee/former Employee’s death) may be eligi-
ble to continue group coverage beyond the date            Notification Requirements
their COBRA and/or Cal-COBRA coverage
ends. Blue Shield will offer the extended cov-            The Employer is solely responsible for notifying
erage to former Employees of employers that               former Employees or Dependent spouses (in-
are subject to the existing COBRA or Cal-                 cluding former spouses as defined above) of the
COBRA, and to the former Employees’ De-                   availability of the coverage at least 90 calendar
pendent spouses, including divorced or wid-               days before COBRA or Cal-COBRA is sched-
owed spouses as defined above. This coverage              uled to end. To elect this coverage, the former
is subject to the following conditions:                   Employee (and/or former spouse) must notify
                                                          the plan in writing at least 30 calendar days be-
1. The former Employee worked for the Em-                 fore COBRA or Cal-COBRA is scheduled to
   ployer for the prior 5 years and was 60 years          end.
   of age or older on the date his/her employ-
   ment ended.                                            Termination of Continuation Coverage after
2. The former Employee was eligible for and               COBRA and/or Cal-COBRA
   elected COBRA and/or Cal-COBRA for                     This coverage will end automatically on the
   himself and his Dependent spouse (a former             earliest of the following dates:
   spouse, i.e., a divorced or widowed spouse
   as defined above, is also eligible for con-            1. the date the former Employee, spouse, or
   tinuation of group coverage after COBRA                   former spouse reaches 65;
   and/or Cal-COBRA. The former spouse
                                                          2. the date the Employer discontinues this
   must elect such coverage by notifying the
                                                             Group Health Service Contract and ceases to
   plan in writing within 30 calendar days prior
                                                             maintain any group health plan for any ac-
   to the date that the former spouse’s initial
                                                             tive Employees;
   COBRA and/or Cal-COBRA benefits are
   scheduled to end).                                     3. the date the former Employee, spouse or
                                                             former spouse transfers to another health
Items 1. and 2. above are not applicable to a                plan, whether or not the benefits of the other
former spouse electing continuation coverage.                health plan are less valuable than those of
If elected, this coverage will begin after the               the health plan maintained by the Employer;
COBRA and/or Cal-COBRA coverage ends and                  4. the date the former Employee, spouse or
will be administered under the same terms and                former spouse becomes entitled to Medi-
conditions as if COBRA and/or Cal-COBRA                      care;
had remained in force.
                                                          5. for a spouse or former spouse, five years
For Persons who transfer to this coverage                    from the date the spouse’s COBRA or Cal-
from COBRA, dues for this coverage shall be                  COBRA coverage would end.
213 percent of the applicable group dues rate,



                                                   -59-
Availability of Blue Shield of                              4. You are covered or eligible for Medicare;
California Individual Conversion Plan
                                                            5. You are covered or eligible for Hospital,
Blue Shield’s Individual Conversion Plan de-                   medical or surgical benefits under state or
scribed below will be available to Persons                     federal law or under any arrangement of
whose continuation of group coverage is termi-                 coverage for individuals in a group, whether
nated or expires while covered under this group                insured or self-insured; and,
plan.
                                                            6. You are covered for similar benefits under
                                                               an individual policy or contract.
INDIVIDUAL CONVERSION PLAN
                                                            Benefits or rates of an individual conversion
Continued Protection                                        health plan are different from those in your
                                                            group plan.
Regardless of age, physical condition or em-
ployment status, you may continue Blue Shield               A conversion plan is also available to:
of California protection when you retire, leave
the job or become ineligible for group coverage.            1. Dependents, if the Subscriber dies;
If you have held group coverage for three or                2. Dependents who marry or exceed the maxi-
more consecutive months, you and your en-                      mum age for Dependent coverage under the
rolled Dependents may apply to transfer to an                  group plan;
individual conversion plan then being issued by
Blue Shield.                                                3. Dependents, if the Subscriber enters military
                                                               service;
Your Employer is solely responsible for notify-
ing you of the availability, terms and conditions           4. Spouse of a Subscriber if their marriage has
of the individual conversion plan within 15 days               been terminated;
of termination of the plan contract.
                                                            5. Dependents, when continuation of coverage
An application and first dues payment for the                  under COBRA and/or Cal-COBRA expires,
individual conversion plan must be received by                 or is terminated.
Blue Shield of California within 63 days of the
date of termination of your group coverage.                 When a Dependent reaches the limiting age for
However, if the group contract is replaced by               coverage as a Dependent, or if a Dependent be-
your Employer with similar coverage under an-               comes ineligible for any of the other reasons
other contract within 15 days, transfer to the in-          given above, it is your responsibility to inform
dividual conversion health plan will not be per-            Blue Shield. Upon receiving notification, Blue
mitted. You will not be permitted to transfer to            Shield of California will offer such Dependent
the individual conversion plan, and coverage                an individual conversion plan for purposes of
under the individual conversion plan will end,              continuous coverage.
under any of the following circumstances:
                                                            EXTENSION OF BENEFITS
1. You failed to pay amounts due the plan;
                                                            If a Person becomes Totally Disabled while
2. You were terminated by the plan for good                 validly covered under this plan and continues to
   cause or for fraud or misrepresentation;                 be Totally Disabled on the date the group con-
3. You knowingly furnished incorrect infor-                 tract terminates, Blue Shield of California will
   mation or otherwise improperly obtained the              extend the benefits of this plan, subject to all
   benefits of the plan;                                    limitations and restrictions, for covered Services
                                                            and supplies directly related to the condition,


                                                     -60-
illness or injury causing such Total Disability              continuing group coverage. Also see the Indi-
until the first to occur of the following: (1)               vidual Conversion Plan provision, and, if appli-
12:01 a.m. on the day following a period of 12               cable, the Continuation of Group Coverage pro-
months from the date coverage terminated; (2)                vision in this booklet for information on
the date the covered Person is no longer Totally             continuation of coverage.
Disabled; (3) the date on which the covered Per-
son's maximum benefits are reached; (4) the                  If your employer is subject to the California
date on which a replacement carrier provides                 Family Rights Act of 1991 and/or the federal
coverage to the Person that is not subject to a              Family & Medical Leave Act of 1993, and the
Pre-Existing Condition exclusion. The time the               approved leave of absence is for family leave
Person was covered under this plan will apply                under the terms of such Act(s), your payment of
toward the replacement plan’s pre-existing con-              dues will keep your coverage in force for such
dition exclusion.                                            period of time as specified in such Act(s). Your
                                                             employer is solely responsible for notifying you
No extension will be granted unless Blue Shield              of the availability and duration of family leaves.
of California receives written certification of
such Total Disability from a licensed Doctor of              Blue Shield of California may terminate your
Medicine (M.D.) within 90 days of the date on                and your Dependent’s coverage for cause im-
which coverage was terminated, and thereafter                mediately upon written notice to you and your
at such reasonable intervals as determined by                Employer for the following:
Blue Shield of California.
                                                             1. Material information that is false, or misrep-
                                                                resented information provided on the en-
TERMINATION OF BENEFITS                                         rollment application or given to your Em-
                                                                ployer or Blue Shield of California; see the
Except as specifically provided under the Exten-                Cancellation/Rescission for Fraud, Mis-
sion of Benefits provision, and, if applicable, the             representations or Omissions provision;
Continuation of Group Coverage provision,
there is no right to receive benefits for Services           2. Permitting use of your Subscriber identifi-
provided following termination of this health                   cation card by someone other than yourself
plan.                                                           or your Dependents to obtain Services;
Coverage for you or your Dependents termi-                   3. Obtaining or attempting to obtain Services
nates at 12:01 a.m. Pacific Time on the earliest                under the group contract by means of false,
of these dates: (1) the date the group contract is              materially misleading, or fraudulent infor-
discontinued, (2) the last day of the month in                  mation, acts or omissions;
which your status as an Employee terminates,
unless a different date on which you no longer               4. Abusive or disruptive behavior which: (1)
meet the requirements for eligibility has been                  threatens the life or well-being of Blue
agreed to between Blue Shield and your Em-                      Shield of California personnel and providers
ployer, (3) the end of the last period for which                of Services, or, (2) substantially impairs the
dues are paid, or (4) the date you or your De-                  ability of Blue Shield of California to ar-
pendents become ineligible. A spouse also be-                   range for services to the Person, or, (3) sub-
comes ineligible following entry of a final de-                 stantially impairs the ability of providers of
cree of divorce, annulment or dissolution of                    Service to furnish Services to the Person or
marriage from the Subscriber. See the “Defini-                  to other patients.
tions” provision.
                                                             If a written application for the addition of a
If you cease work because of retirement, dis-                newborn or a child placed for adoption is not
ability, leave of absence, temporary layoff or               submitted to and received by Blue Shield within
termination, see your Employer about possibly                31 days following that Dependent's effective

                                                      -61-
date of coverage, benefits under this plan will be          payment of dues, no benefits will be provided
terminated on the 32nd day at 12:01 a.m. Pacific            unless you obtain an Extension of Benefits.
Time.
                                                            Misrepresentations or omissions on an applica-
                                                            tion or a health statement (if a health statement
REINSTATEMENT, CANCELLATION                                 is required by the Employer) may result in the
AND RESCISSION PROVISIONS                                   cancellation or rescission of this group health
                                                            plan. Cancellations are effective on receipt or
Reinstatement                                               on such later date as specified in the cancella-
                                                            tion notice.
If you had been making contributions toward
coverage for you and your Dependents and vol-               In the event the contract is rescinded or can-
untarily canceled such coverage, you may apply              celed, either by Blue Shield of California or
for reinstatement. You or your Dependents                   your Employer, it is your Employer's responsi-
must wait until the earlier of 12 months from the           bility to notify you of the rescission or cancella-
date of application to be reinstated or at the Em-          tion.
ployer’s next open enrollment period. Blue
Shield will not consider applications for earlier           Right of Cancellation
effective dates.
                                                            If you are making any contributions toward
Cancellation Without Cause                                  coverage for yourself or your Dependents, you
                                                            may cancel such coverage to be effective at the
This group health plan may be canceled by your              end of any period for which dues have been
employer at any time provided written notice is             paid.
given to Blue Shield of California to become ef-
fective upon receipt, or on a later date as may be          Any dues paid Blue Shield of California for a
specified by the notice.                                    period extending beyond the cancellation date
                                                            will be refunded to your Employer. Your Em-
Cancellation for Non-Payment of Dues                        ployer will be responsible to Blue Shield of
                                                            California for unpaid dues prior to the date of
Blue Shield of California may cancel this group             cancellation.
health plan for non-payment of dues, after hav-
ing given at least 15 days’ written notice to your          Blue Shield of California will honor all claims
Employer, stating when such cancellation will               for covered Services provided prior to the ef-
become effective, retroactive to the last day of            fective date of cancellation.
the period for which dues are paid.
                                                            See the Cancellation and Rescission provision
                                                            for termination for misrepresentations or omis-
Cancellation/Rescission for Fraud,                          sions.
Misrepresentations or Omissions
Blue Shield of California may cancel the group              LIABILITY OF SUBSCRIBERS IN THE EVENT OF
contract for fraud or misrepresentation by your             NON-PAYMENT BY BLUE SHIELD
Employer, or with respect to coverage of Em-
ployees or Dependents, for fraud or misrepre-               In accordance with Blue Shield's established
sentation of the Employee, Dependent, or their              policies, and by statute, every contract between
representative.                                             Blue Shield of California and its Participating
                                                            Providers and Preferred Providers stipulates that
If you are hospitalized or undergoing treatment             the Subscriber shall not be responsible to the
for an ongoing condition and the group contract             Participating Provider or Preferred Provider for
is canceled for any reason, including non-                  compensation for any Services to the extent that


                                                     -62-
they are provided in the Subscriber's group con-            PLAN INTERPRETATION
tract. When Services are provided by a Partici-
pating Provider or Preferred Provider, the Sub-             Blue Shield of California shall have the power
scriber is responsible for applicable deductibles,          and discretionary authority to construe and in-
copayments and charges in excess of the benefit             terpret the provisions of this plan, to determine
maximums.                                                   the benefits of this plan and determine eligibility
                                                            to receive benefits under this plan. Blue Shield
If Services are provided by a Non-Preferred                 of California shall exercise this authority for the
Provider, the Subscriber is responsible for all             benefit of all Persons entitled to receive benefits
amounts Blue Shield of California does not pay.             under this plan.
When a benefit specifies a benefit maximum
and that benefit maximum has been reached, the              CUSTOMER SERVICE
Subscriber is responsible for any charges above
                                                            If you have a question about Services, provid-
the benefit maximums.
                                                            ers, benefits, how to use this plan, or concerns
                                                            regarding the quality of care or access to care
NON-ASSIGNABILITY                                           that you have experienced, you may contact
                                                            Blue Shield’s Customer Service Department as
Coverage or any benefits of this plan may not be            noted on the last page of this booklet.
assigned without the written consent of Blue
Shield of California.                                       The hearing impaired may contact Blue Shield’s
                                                            Customer Service Department through Blue
Possession of a Blue Shield of California ID                Shield’s toll-free TTY number, 1-800-241-1823.
card confers no right to Services or other bene-
fits of this plan. To be entitled to Services, the          Customer Service can answer many questions
Person must be a Subscriber who has been ac-                over the telephone.
cepted by the Employer and enrolled by Blue
Shield of California and who has maintained en-             Note: Blue Shield of California has established
rollment under the terms of this plan.                      a procedure for our Subscribers and Dependents
                                                            to request an expedited decision. A Person,
Participating Providers and Preferred Providers             Physician, or representative of a Person may
are paid directly by Blue Shield. The Person or             request an expedited decision when the routine
the provider of Service may not request that                decision making process might seriously
payment be made directly to any other party.                jeopardize the life or health of a Person, or when
                                                            the Person is experiencing severe pain. Blue
If the Person receives Services from a Non-                 Shield shall make a decision and notify the
Preferred Provider, payment will be made di-
                                                            Person and Physician within 72 hours following
rectly to the Subscriber, and the Subscriber is
                                                            the receipt of the request.         An expedited
responsible for payment to the Non-Preferred
                                                            decision may involve admissions, continued
Provider. The Person or the provider of Service
                                                            stay or other healthcare Services. If you would
may not request that the payment be made di-
                                                            like additional information regarding the
rectly to the provider of service.
                                                            expedited decision process, or if you believe
                                                            your particular situation qualifies for an
SERVICES FOR EMERGENCY CARE                                 expedited decision, please contact our Customer
                                                            Service Department at the number provided on
The benefits of this plan will be provided for
                                                            the last page of this booklet.
covered Services received anywhere in the
world for the emergency care of an illness or
injury.



                                                     -63-
GRIEVANCE PROCESS                                          External Independent Medical Review
Blue Shield of California has established an ap-           If your appeal involves a claim or services for
peals procedure for receiving, resolving and               which coverage was denied by Blue Shield or
tracking Subscribers’ grievances with Blue                 by a contracting provider in whole or in part on
Shield of California.                                      the grounds that the service is not Medically
                                                           Necessary or is experimental/investigational
Subscribers may contact the Customer Service               (including the external review available under
Department by telephone, letter or on-line to re-          the Friedman-Knowles Experimental Treatment
quest a review of an initial determination con-            Act of 1996), you may choose to make a request
cerning a claim or service. Subscribers may                to the Department of Managed Health Care to
contact the Plan at the telephone number as                have the matter submitted to an independent
noted on the enclosed Supplement. If the tele-             agency for external review in accordance with
phone inquiry to Customer Service does not re-             California law. You normally must first request
solve the question or issue to the Subscriber’s            an appeal from Blue Shield and wait for at least
satisfaction, the Subscriber may request a griev-          30 days before you request external review;
ance at that time, which the Customer Service              however, if your matter would qualify for an
Representative will initiate on the Subscriber’s           expedited decision as described above or in-
behalf.                                                    volves a determination that the requested service
                                                           is experimental/investigational, you may imme-
The Subscriber may also initiate a grievance by
                                                           diately request an external review following re-
submitting a letter or a completed “Grievance
                                                           ceipt of notice of denial. You may initiate this
Form”. The Subscriber may request this Form
                                                           review by completing an application for external
from Customer Service. The completed form
                                                           review, a copy of which can be obtained by
should be submitted to Customer Service at the
                                                           contacting Customer Service. The Department
address as noted on the enclosed Supplement.
                                                           of Managed Health Care will review the appli-
The Subscriber may also submit the grievance
                                                           cation and, if the request qualifies for external
online by visiting our web site at
                                                           review, will select an external review agency
http://www.mylifepath.com.
                                                           and have your records submitted to a qualified
Blue Shield will acknowledge receipt of a                  specialist for an independent determination of
grievance within 5 calendar days. Grievances               whether the care is Medically Necessary. You
are resolved within 30 days. The grievance                 may choose to submit additional records to the
system allows Subscribers to file grievances for           external review agency for review. There is no
at least 180 days following any incident or ac-            cost to you for this external review. You and
tion that is the subject of the Subscriber’s dis-          your physician will receive copies of the opin-
satisfaction. See the previous Customer Service            ions of the external review agency. The deci-
section for information on the expedited deci-             sion of the external review agency is binding on
sion process.                                              Blue Shield; if the external reviewer determines
                                                           that the service is Medically Necessary, Blue
NOTE: If your Employer’s health Plan is gov-               Shield will promptly arrange for the service to
erned by the Employee Retirement Income Se-                be provided. This external review process is in
curity Act (“ERISA”), you may have the right to            addition to any other procedures or remedies
bring a civil action under Section 502(a) of               available to you and is completely voluntary on
ERISA if all required reviews of your claim                your part; you are not obligated to request ex-
have been completed and your claim has not                 ternal review. However, failure to participate in
been approved.                                             external review may cause you to give up any
                                                           statutory right to pursue legal action against




                                                    -64-
Blue Shield regarding the disputed service. For            PUBLIC POLICY PARTICIPATION
more information regarding the external review             PROCEDURE
process, or to request an application form,
please contact Customer Service.                           This procedure enables you to participate in es-
                                                           tablished public policy of Blue Shield of Cali-
DEPARTMENT OF MANAGED HEALTH                               fornia. It is not to be used as a substitute for the
CARE REVIEW                                                appeal procedure, complaints, inquiries or re-
                                                           quests for information.
The California Department of Managed Health
Care is responsible for regulating health care             Public policy means acts performed by a plan or
                                                           its Employees and staff to assure the comfort,
service plans. If you have a grievance against
                                                           dignity, and convenience of Persons who rely on
your health plan, you should first telephone your
                                                           the plan's facilities to provide health care Serv-
health plan at the number provided on the last
                                                           ices to them, their families, and the public (Cali-
page of this booklet and use your health plan’s
                                                           fornia Health and Safety Code, §1369).
grievance process before contacting the De-
partment. Utilizing this grievance procedure               At least one third of the Board of Directors of
does not prohibit any potential legal rights or            Blue Shield of California is comprised of Sub-
remedies that may be available to you. If you              scribers who are not Employees, providers, sub-
need help with a grievance involving an emer-              contractors or group contract brokers and who
gency, a grievance that has not been satisfacto-           do not have financial interests in Blue Shield.
rily resolved by your health plan, or a grievance          The names of the members of the Board of Di-
that has remained unresolved for more than 30              rectors may be obtained from:
days, you may call the Department for assis-
tance. You may also be eligible for an Inde-                      Director, Consumer Affairs
pendent Medical Review (IMR). If you are eli-                     Blue Shield of California
gible for IMR, the IMR process will provide an                    50 Beale Street
impartial review of medical decisions made by a                   San Francisco, CA 94105
health plan related to the medical necessity of a                 Phone: 1-415-229-5104
proposed service or treatment, coverage deci-
sions for treatments that are experimental or in-          Procedure:
vestigational in nature and payment disputes for
emergency or urgent medical services. The                  1. Your recommendations, suggestions or
Department also has a toll-free telephone                     comments should be submitted in writing to
number (1-888-HMO-2219) and a TDD line                        the Director, Consumer Affairs, at the above
(1-877-688-9891) for the hearing and speech                   address, who will acknowledge receipt of
impaired. The Department’s Internet Web                       your letter.
site (http://www.hmohelp.ca.gov) has com-
plaint forms, IMR application forms and in-                2. Your name, address, phone number, Sub-
                                                              scriber number and group number should be
structions online.
                                                              included with each communication.
In the event that Blue Shield should cancel or
                                                           3. The policy issue should be stated so that it
refuse to renew the enrollment for you or your
                                                              will be readily understood. Submit all rele-
Dependents and you feel that such action was
                                                              vant information and reasons for the policy
due to health or utilization of Benefits, you or
                                                              issue with your letter.
your Dependents may request a review by the
Department of Managed Health Care Director.                4. Policy issues will be heard at least quarterly
                                                              as agenda items for meetings of the Board of



                                                    -65-
   Directors. Minutes of Board meetings will               the last page of this booklet, or by accessing
   reflect decisions on public policy issues that          Blue Shield of California’s internet site located
   were considered. If you have initiated a                at http://www.mylifepath.com and printing a
   policy issue, appropriate extracts of the               copy.
   minutes will be furnished to you within 10
   business days after the minutes have been               If you are concerned that Blue Shield may have
   approved.                                               violated your confidentiality/privacy rights, or
                                                           you disagree with a decision we made about ac-
                                                           cess to your personal and health information,
CONFIDENTIALITY OF PERSONAL AND                            you may contact us at:
HEALTH INFORMATION
                                                           Correspondence Address:
Blue Shield of California protects the confiden-
tiality/privacy of your personal and health in-            Blue Shield of California Privacy Official
formation. Personal and health information in-             P.O. Box 272540
cludes both medical information and                        Chico, CA 95927-2540
individually identifiable information, such as             Toll-Free Telephone:
your name, address, telephone number or social
security number. Blue Shield will not disclose             1-888-266-8080
this information without your authorization, ex-
cept as permitted by law.                                  Email Address:
                                                           blueshieldca_privacy@blueshieldca.com
A STATEMENT DESCRIBING BLUE SHIELD'S
POLICIES AND PROCEDURES FOR PRESERV-
ING THE CONFIDENTIALITY OF MEDICAL                         INDEPENDENT CONTRACTORS
RECORDS IS AVAILABLE AND WILL BE FUR-                      Providers are neither agents nor employees of
NISHED TO YOU UPON REQUEST. Blue                           the plan but are independent contractors. In no
Shield’s policies and procedures regarding our             instance shall the plan be liable for the negli-
confidentiality/privacy practices are contained            gence, wrongful acts or omissions of any person
in the “Notice of Privacy Practices”, which you            receiving or providing services, including any
may obtain either by calling the Customer                  physician, hospital, or other provider or their
Service Department at the number provided on               employees.




                                                    -66-
  Blue Shield of California
        Vision Plan




The vision benefits provided pursuant to this
Vision Plan Supplement are separate from the
medical benefits provided pursuant to the
Group Health Service Contract. The vision
benefits are not subject to the Group Health
Service Contract's Deductible requirements
nor do they cumulate towards the Maximum
Calendar Year Copayment responsibility.
Further, the Group Health Service Contract's
Individual Conversion Plan and Extension of
Benefits provisions do not apply. Otherwise,
the Group Health Service Contract's general
provisions and exclusions shall apply.




                       67
INTRODUCTION                                                 ELIGIBILITY, EFFECTIVE DATE,
                                                             AND TERMINATION PROVISIONS
The vision benefits are designed to reduce the cost
of vision care while promoting quality eye care              The date of eligibility, the effective date of bene-
coverage services. In order to reduce costs, respon-         fits, and the date of discontinuance of benefits for
sibility is placed on the Subscriber for managing the        Subscribers and Dependents follow the same eli-
benefits provided for under this Vision Plan.                gibility, effective date, and discontinuance of
                                                             benefits provisions of the Group Health Service
The Subscriber is responsible for assuring that the          Contract.
eye care professional chosen is a Participating
Provider in order to maximize benefit allowances.
                                                             CLAIMS REVIEW
DEFINITIONS                                                  Medical Eye Services and Blue Shield of Califor-
                                                             nia reserve the right to review all claims to de-
Whenever any of the following terms are capital-             termine whether any exclusions or limitations ap-
ized in this Vision Plan, they will have the                 ply.
meaning below:
                                                             Medical Eye Services and Blue Shield of Califor-
Allowed Amount – the Blue Shield of California               nia may use the services of physician consultants,
   Allowance for covered eye services as de-
                                                             peer review committees of professional societies
   scribed herein. For Participating Providers,
                                                             and other consultants to evaluate claims.
   the Allowance agreed upon between Blue
   Shield of California and Medical Eye Serv-
   ices, Inc. and which Participating Providers              BENEFITS
   have agreed to accept as payment in full for              Blue Shield will pay for covered Services
   covered Services as set forth in this Supple-             rendered by ECN Participating Providers in full,
   ment.                                                     except for charges for cosmetic/convenience
ECN — Eye Care Network (ECN) is a California                 contact lenses and frames which Blue Shield will
  corporation which makes available to Blue                  reimburse up to the Allowed Amounts listed in
  Shield its contracting network of Participating            the Schedule of Allowances. Subscribers will be
  Provider ophthalmologists, optometrists and                responsible for charges which exceed the
  opticians for the provision of services under              Allowed Amount. Charges for frames or unusual
  this Vision Plan.                                          lenses, such as oversize, which exceed the
                                                             Allowed Amount will be the responsibility of the
MES — Medical Eye Services, Inc. (MES) is a                  Subscriber.
  California corporation which has an agree-
  ment with Blue Shield to administer claims on              For covered Services rendered by non-
  Blue Shield's behalf for eyewear and eye ex-               Participating Providers, Blue Shield will pay up
  ams covered under this Vision Plan. The                    to the amounts listed in the Schedule of
  MES address is P.O. Box 25208, Santa Ana,                  Allowances. Subscribers will be responsible for
  CA 92799-5208, telephone 1-714-619-4660                    all charges in excess of those amounts.
  or 1-800-877-6372.                                         Covered Services under this Supplement are
Participating Provider — a licensed ophthal-                 limited to the following:
   mologist, optometrist or optician who has                 1. One comprehensive eye examination in a 12
   certified his willingness to accept the terms                consecutive month period. A comprehensive
   and conditions and compensations as payment                  examination represents a level of service in
   in full for covered Services as set forth in this            which a general evaluation of the complete
   Supplement.                                                  visual system is made. The comprehensive

                                                        68
   services constitute a single service entity but           sion, Blue Shield's liability for services
   need not be performed at one session. The                 provided for the treatment of any one ill-
   service includes history, general medical ob-             ness or injury shall be reduced by the
   servation, external and opthalmoscopic exami-             amount of benefits paid, or the reasonable
   nation, gross visual fields and basic sensori-            value or the amount of Blue Shield's fee-
   motor examination. It often includes as                   for-service payment to the provider,
   indicated: biomicroscopy, examination for cy-             whichever is less, of the services provided
   cloplegia or mydriasis, tonometry, and, usu-              without any liability for the cost thereof,
   ally, determination of the refractive state un-           for the treatment of that same illness or in-
   less known, or unless the condition of the                jury as a result of the Subscriber's entitle-
   media precludes this or it is otherwise contra-           ment to such other benefits.
   indicated, as in presence of trauma or severe
   inflammation.                                             This exclusion is applicable to:

2. One pair of lenses in a 24 consecutive month              a. any services and supplies provided to
   period, or at a 12 month interval if the exami-              the Subscriber by any federal or state
   nation indicates a prescription change.                      governmental agency, or by any mu-
                                                                nicipality, county, or other political
3. One frame in a 24 consecutive month period.                  subdivision. However, this paragraph
                                                                does not apply to benefits provided un-
4. Medically necessary contact lenses, when re-                 der Chapters 7 and 8 of Part 3, Division
   quired for severe anisometropia, keratoconus                 9 of the California Welfare and Institu-
   following cataract surgery, or for severe high               tions Code ("Medi-Cal"), or Subchap-
   myopia, hyperopia or astigmatism.                            ter 19 (commencing with Section 1396)
                                                                of Chapter 7 of Title 42 of the United
5. Contact lenses for cosmetic reasons or for
                                                                States Code or for the reasonable costs
   convenience when provided in lieu of other
                                                                of Services provided to the Subscriber
   eyewear once every 24 consecutive months,
                                                                at a Veterans Administration facility
   or at a 12 month interval if the examination
                                                                for a condition unrelated to military
   indicates a prescription change.
                                                                service or at a Department of Defense
   NOTE: A prescription change means any                        facility, provided the Subscriber is not
   of the following:                                            on active duty;

   a. A change in prescription of 0.50 diopter               b. benefits provided under any other vi-
      or more in one or both eyes;                              sion plan, but only to the extent that
                                                                such benefits are provided in the form
   b. A shift in axis of astigmatism of 15 de-                  of vision care services and supplies
      grees; or                                                 rather than payment of or reimburse-
                                                                ment for the cost of such services and
   c. A difference in vertical prism greater than               supplies.
      1 prism diopter
                                                          2. Unless exemptions to the following General
GENERAL EXCLUSIONS                                           Exclusions are specifically made elsewhere
                                                             in this Supplement, this Vision Plan does
1. Exclusion for Duplicate Coverage. In the                  not provide benefits for:
   event that the Subscriber is both enrolled
   under this Vision Plan and entitled to bene-              a. orthoptics or vision training, subnormal
   fits under any of the conditions described                   vision aids or non-prescription lenses
   in paragraphs (a.) and (b.) of this exclu-                   for glasses when no prescription change
                                                                is indicated;


                                                     69
b. coated lenses, no-line bifocal (blended                  pay, or services and materials for which
   type) lenses or oversized lenses exceed-                 no charge is made to the Subscriber.
   ing the allowance for covered lenses;
                                                     PAYMENT OF BENEFITS
c. replacement or repair of lost or broken
   lenses or frames, except at the normal            Prior to service, a Subscriber should obtain a vi-
   intervals;                                        sion service report form (Form C-4669), which
                                                     must be completed by the Participating Provider
d. any eye examination required by the               and submitted directly to MES. (C-4669 forms
   employer as a condition of employment;
                                                     are available from your group administrator.)
e. medical or surgical treatment of the              Participating Providers will accept Blue Shield's
   eyes;                                             payment for covered services as payment in full,
                                                     except as noted in the Schedule of Allowances.
f. services performed by a Close Relative            The Subscriber will be responsible for any differ-
   or by an individual who ordinarily re-            ence between the amount billed by a Non-
   sides in the Subscriber’s or Dependent's          Participating Provider and the amount paid by
   home;                                             Blue Shield. MES will make payment directly to a
                                                     Participating Provider, or to the Subscriber for the
g. services performed incident to any in-            services of a Non-Participating Provider, by means
   jury or disease arising out of, or in the         of a Blue Shield check. A list of Participating
   course of, any employment for salary,             Providers may be obtained from the Subscriber’s
   wage or profit if such injury or disease          group administrator or from MES.
   is covered by any workers' compensa-
   tion law, occupational disease law or             Every contract between ECN and its Participating
   similar legislation. However, if Blue             Providers stipulates that the Subscriber shall not
   Shield provides payment for such serv-            be responsible to the Participating Provider for
   ices, it shall be entitled to establish a         compensation with respect to any services to the
   lien upon such other benefits up to the           extent that they are provided in this Vision Plan.
   amount paid by Blue Shield for the                When services are provided by a Non-Participating
   treatment of the injury or disease;               Provider, the Subscriber is responsible for any
                                                     amount Blue Shield does not pay, provided how-
h. contact lenses, except as specifically            ever that if a Subscriber is receiving services from
   provided;                                         a Participating Provider as of the date that such
                                                     provider's contract with ECN is terminated, the
i. services required by any government
                                                     Subscriber's responsibility to that provider for
   agency or program, Federal, State or
                                                     services rendered subsequent to that termination
   subdivision thereof;
                                                     date shall be no greater than it was for services
j. treatment directly related to any totally         rendered immediately prior to that termination
   disabling condition, illness or injury for        date, until the first to occur of the following:
   which an extension of benefits is pro-
                                                     1. the date that the services being rendered by
   vided under a contract or policy pro-
                                                        such provider are completed;
   viding hospital, medical or surgical ex-
   pense or service benefits that was in             2. the date that ECN makes reasonable and ap-
   effect with the employer within 60 days              propriate provision for the assumption of such
   immediately before the effective date of             services by another Participating Provider;
   this contract;
                                                     3. the date that coverage for such Subscriber is
k. services and materials for which the                 terminated.
   Subscriber is not legally obligated to


                                                70
Participating Providers submit claims for pay-           ered services hereunder, including such providers
ment after their services have been received. You        outside of California. The Subscriber may con-
or your Non-Participating Providers also submit          tact the group administrator or MES for a Direc-
claims for payment after services have been re-          tory of Participating Providers.
ceived.
                                                         CUSTOMER SERVICE
Providers do not receive financial incentives or
bonuses from Blue Shield of California.                  If you have a question about services, your bene-
                                                         fits, or a provider, or concerns regarding the
PLEASE READ THE FOLLOWING INFOR-
                                                         quality of care or access to care that you have ex-
MATION SO YOU WILL KNOW FROM
                                                         perienced, you may contact:
WHOM OR WHAT GROUP OF PROVIDERS
CARE MAY BE OBTAINED.                                            Medical Eye Services
                                                                 Customer Service Department
CHOICE OF PROVIDERS                                              P.O. Box 25208
                                                                 Santa Ana, CA 92799-5208
A Subscriber may select any licensed ophthal-                    1-714-619-4660 or 1-800-877-6372.
mologist, optometrist or optician to provide cov-




                                                    71
SCHEDULE OF ALLOWANCES
                     Procedure                Participating Provider              Non-Participating Provider
                                                                               Services are covered up to the fol-
                                                                               lowing Allowed Amounts with
                                                                               Subscribers being responsible for
                                                                               all charges in excess of these
                                                                               amounts.
    Comprehensive examination:
          Ophthalmologic                                                                         $60
          Optometric                                                                              50
    Brief visit1                                                                                 20
    Limited visit1                                    These                                      25
    Intermediate visit1                              Services                                    30
    Lenses*:                                            are
            Single Vision                            covered                                     43
            Bifocal                                   in full                                    60
            Trifocal                                  when                                       75
            7.25 Diopter, or more                    received                                    12
            Aphakic Monofocal                          from                                      120
            Aphakic Multifocal                     Participating                                 200
            Lenticular Monofocal                    Providers.                                   120
           Lenticular Multifocal                                                                 200
           Prism 1 1/2 to 4 Diopters                                                              10
           Prism 4 1/2 to 10 Diopters                                                             16
           Slab-off prism (per lens)                                                              35
    Contact Lenses:
            Medically necessary (Hard)                                                           200
            Medically necessary (Soft)                                                           250
    Cosmetic/Convenience Contact Lenses Covered up to a maximum                                 1202
    (Hard/Soft)                         of $1202
    Frame                                    Covered up to a maximum                             40
                                             of $100
1
    When in lieu of a comprehensive exam.
2
    Allowance toward the cost is in lieu of other eyewear benefits — the difference between the Allowance and
    the provider's charge is the responsibility of the Subscriber, whether dispensed by a Participating Provider or
    by a Non-Participating Provider.
 *Each pair of lenses includes Pink or Rose tint #1 or #2 in the allowance.
NOTE: The difference between the Allowed Amount and the charges for more expensive frames or unusual
lenses, such as oversize, will be the responsibility of the Subscriber, whether dispensed by a Participating Pro-
vider or by a Non-Participating Provider. Participating Providers allow a selection from frame styles that retail to
$100 with lenses that fit an eye size less than 61 millimeters. If a more expensive frame is selected, the Subscriber
is responsible for the additional cost above $100. If the lenses are 61 millimeters or over, any difference between the
Allowance and the provider's charge is the responsibility of the Subscriber.

                                                          72
NOTES




 73
NOTES




 74
NOTES




 75
           Blue Shield of California Customer Service Office to Serve You




                     For claims submission and information contact:

                          BLUE SHIELD OF CALIFORNIA
                                   P.O. Box 272540
                                Chico, CA 95927-2540

                                 You may call toll free:

                          Customer Service: 1-800-200-3242
                The hearing impaired may contact Blue Shield’s Cus-
                tomer Service Department through Blue Shield’s toll-
                       free TTY number at 1-800-241-1823.

                 Benefits Management Program Telephone Numbers
                     For Preadmission Review: 1-800-343-1691

                   For Prior Authorization of Benefits Management
                   Program Radiological Services: 1-888-642-2583
            Please refer to the Benefits Management Program section of this
           Evidence of Coverage and Disclosure Form booklet for information.




977662 (1/04)
PPOCov (7/01)

								
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