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					HDHP Preferred Savings Plan




                                        An Independent Member of the Blue Shield Association
            Benefit Booklet
     CSAC Excess Insurance Authority
        County of Santa Barbara
          Group Number: E10059
      Effective Date: January 1, 2011
                                                    NOTICE
    This Benefit Booklet describes the terms and conditions of coverage of your Claims Administrator health
    Plan. It is your right to view the Benefit Booklet prior to enrollment in the health Plan.
    Please read this Benefit Booklet carefully and completely so that you understand which services are cov-
    ered health care Services, and the limitations and exclusions that apply to your Plan. If you or your De-
    pendents 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 the Claims Administrator 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 ser-
    vices 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 deliv-
    ery; infertility treatments; or abortion. You should obtain more information before
    you enroll. Call your prospective doctor, medical group, independent practice asso-
    ciation, or clinic, or call the health Plan at the Claims Administrator’s Customer
    Service telephone number listed in the back of this booklet to ensure that you can
    obtain the health care services that you need.




psp2250 (10/10)




                                                        1
This Plan is intended to qualify as a “high deductible health plan” for the purposes of qualifying for a health savings account
(HSA), within the meaning of Section 223 of the Internal Revenue Code of 1986, as amended. Although the Claims Adminis-
trator believes that this Plan meets these requirements, the Internal Revenue Service has not ruled on whether the Plan is quali-
fied as a high deductible health plan. In the event that any court, agency, or administrative body with jurisdiction over the matter
makes a final determination that this Plan does not qualify, the Claims Administrator will make efforts to amend this Plan, if
necessary, to meet the requirements of a qualified plan. If the Claims Administrator determines that the amendment necessitates
a change in the Plan provisions, the Claims Administrator will provide written notice of the change, and the change shall become
effective on the date provided in the written notice.
Important Information Regarding HSAs
The Claims Administrator Preferred Savings Plan is not a “Health Savings Account” or an “HSA”, but is designed as a “high
deductible health plan” that may allow you, if you are eligible, to take advantage of the income tax benefits available to you
when you establish an HSA and use the money you put into the HSA to pay for qualified medical expenses subject to the de-
ductibles under this Plan.
If this Plan was selected in order to obtain the income tax benefits associated with an HSA and the Internal Revenue Service
were to rule that this Plan does not qualify as a high deductible health plan, you may not be eligible for the income tax benefits
associated with an HSA. In this instance, you may have adverse income tax consequences with respect to your HSA for all
years in which you were not eligible.
NOTICE: The Claims Administrator does not provide tax advice. If you intend to purchase this Plan to use with an HSA for tax
purposes, you should consult with your tax advisor about whether you are eligible and whether your HSA meets all legal re-
quirements.
If you are interested in learning more about Health Savings Accounts, eligibility and the law's current provisions, ask your bene-
fits administrator and consult with a financial advisor.




                                                                 2
The Preferred Savings Plan
Participant Bill of Rights
As a Preferred Savings Plan Participant, you have the right to:
1.   Receive considerate and courteous care, with respect             9.   Receive preventive health Services.
     for your right to personal privacy and dignity.
                                                                      10. Know and understand your medical condition, treat-
2.   Receive information about all health Services avail-                 ment plan, expected outcome, and the effects these
     able to you, including a clear explanation of how to                 have on your daily living.
     obtain them.
                                                                      11. Have confidential health records, except when disclo-
3.   Receive information about your rights and responsi-                  sure is required by law or permitted in writing by
     bilities.                                                            you. With adequate notice, you have the right to re-
                                                                          view your medical record with your Physician.
4.   Receive information about your Preferred Savings
     Plan, the Services we offer you, the Physicians and              12. Communicate with and receive information from
     other practitioners available to care for you.                       Customer Service in a language you can understand.
5.   Have reasonable access to appropriate medical ser-               13. Know about any transfer to another Hospital, includ-
     vices.                                                               ing information as to why the transfer is necessary
                                                                          and any alternatives available.
6.   Participate actively with your Physician in decisions
     regarding your medical care. To the extent permitted             14. Be fully informed about the Claims Administrator
     by law, you also have the right to refuse treatment.                 dispute procedure and understand how to use it with-
                                                                          out fear of interruption of health care.
7.   A candid discussion of appropriate or Medically
     Necessary treatment options for your condition, re-              15. Voice complaints or grievances about the Preferred
     gardless of cost or benefit coverage.                                Savings Plan or the care provided to you.
8.   Receive from your Physician an understanding of
     your medical condition and any proposed appropriate
     or Medically Necessary treatment alternatives, includ-
     ing available success/outcomes information, regardless
     of cost or benefit coverage, so you can make an in-
     formed decision before you receive treatment.




                                                                  3
The Preferred Savings Plan
Participant Responsibilities
As a Preferred Savings Plan Participant, you have the responsibility to:
1.   Carefully read all the Claims Administrator Preferred            6.   Make and keep medical appointments and inform
     Savings Plan materials immediately after you are en-                  your Physician ahead of time when you must cancel.
     rolled so you understand how to use your Benefits
                                                                      7.   Communicate openly with the Physician you choose
     and how to minimize your out of pocket costs. Ask
                                                                           so you can develop a strong partnership based on
     questions when necessary. You have the responsibil-
                                                                           trust and cooperation.
     ity to follow the provisions of your Claims Adminis-
     trator Preferred Savings Plan membership as ex-                  8.   Offer suggestions to improve the Claims Administra-
     plained in the Benefit Booklet.                                       tor Preferred Savings Plan.
2.   Maintain your good health and prevent illness by                 9.   Help the Claims Administrator to maintain accurate
     making positive health choices and seeking appropri-                  and current medical records by providing timely in-
     ate care when it is needed.                                           formation regarding changes in address, family status
                                                                           and other health plan coverage.
3.   Provide, to the extent possible, information that your
     Physician, and/or the Plan need to provide appropri-             10. Notify the Claims Administrator as soon as possible
     ate care for you.                                                    if you are billed inappropriately or if you have any
                                                                          complaints.
4.   Follow the treatment plans and instructions you and
     your Physician have agreed to and consider the po-               11. Treat all Plan personnel respectfully and courteously
     tential consequences if you refuse to comply with                    as partners in good health care.
     treatment plans or recommendations.
                                                                      12. Pay your fees, Copayments and charges for non-
5.   Ask questions about your medical condition and                       covered services on time.
     make certain that you understand the explanations
     and instructions you are given.                                  13. Follow the provisions of the Claims Administrator
                                                                          Benefits Management Program.




                                                                4
TABLE OF CONTENTS
HDHP PREFERRED SAVINGS PLAN SUMMARY OF BENEFITS ........................................................................................................ 8
WHAT IS A HEALTH SAVINGS ACCOUNT (HSA)? ........................................................................................................................ 19
HOW A HEALTH SAVINGS ACCOUNT WORKS ............................................................................................................................. 19
INTRODUCTION TO THE CLAIMS ADMINISTRATOR PREFERRED SAVINGS PLAN .......................................................................... 19
CLAIMS ADMINISTRATOR PREFERRED PROVIDERS ..................................................................................................................... 19
    Continuity of Care by a Terminated Provider ............................................................................................................................20
    Financial Responsibility for Continuity of Care Services..........................................................................................................20
    Submitting a Claim Form............................................................................................................................................................20
ELIGIBILITY ................................................................................................................................................................................ 20
EFFECTIVE DATE OF COVERAGE................................................................................................................................................. 21
MEDICAL CARE BENEFITS .......................................................................................................................................................... 22
    Annual Open Enrollment ............................................................................................................................................................22
    Special Enrollment Event............................................................................................................................................................22
    Effective Date for Late Enrollees................................................................................................................................................23
RENEWAL OF PLAN ..................................................................................................................................................................... 23
SERVICES FOR EMERGENCY CARE .............................................................................................................................................. 23
SECOND MEDICAL OPINION POLICY ........................................................................................................................................... 23
HEALTH EDUCATION AND HEALTH PROMOTION SERVICES ........................................................................................................ 23
RETAIL-BASED HEALTH CLINICS ............................................................................................................................................... 23
THE CLAIMS ADMINISTRATOR ONLINE ...................................................................................................................................... 23
BENEFITS MANAGEMENT PROGRAM .......................................................................................................................................... 23
    Prior Authorization......................................................................................................................................................................24
    Hospital and Skilled Nursing Facility Admissions.....................................................................................................................25
    Emergency Admission Notification............................................................................................................................................26
    Hospital Inpatient Review...........................................................................................................................................................26
    Discharge Planning......................................................................................................................................................................26
    Case Management .......................................................................................................................................................................26
REDUCED PAYMENTS FOR FAILURE TO USE THE BENEFITS MANAGEMENT PROGRAM ............................................................... 27
DEDUCTIBLES ............................................................................................................................................................................. 27
    1. Individual Coverage Deductible (applicable to 1 Member coverage)................................................................................27
    2. Family Coverage Deductible (applicable to 2 or more Member coverage) .......................................................................27
    Services Not Subject to the Deductible ......................................................................................................................................27
    Last Quarter Carry Over..............................................................................................................................................................27
    Prior Carrier Deductible Credit...................................................................................................................................................28
MAXIMUM AGGREGATE PAYMENT AMOUNT ............................................................................................................................. 28
PAYMENT ................................................................................................................................................................................... 28
CALENDAR YEAR MAXIMUM OUT-OF-POCKET RESPONSIBILITY ............................................................................................... 29
    1. Individual Coverage (applicable to 1 Member coverage)...................................................................................................29
    2. Family Coverage (applicable to 2 or more Member coverage)..........................................................................................29
PRINCIPAL BENEFITS AND COVERAGES (COVERED SERVICES)................................................................................................... 30
    Acupuncture Benefits..................................................................................................................................................................30
    Allergy Testing and Treatment Benefits.....................................................................................................................................30
    Ambulance Benefits ....................................................................................................................................................................30
    Ambulatory Surgery Center Benefits .........................................................................................................................................30
    Bariatric Surgery Benefits...........................................................................................................................................................30
    Chiropractic Benefits...................................................................................................................................................................30
    Clinical Trial for Cancer Benefits...............................................................................................................................................31
    Diabetes Care Benefits ................................................................................................................................................................31
    Dialysis Center Benefits..............................................................................................................................................................31
    Durable Medical Equipment Benefits.........................................................................................................................................32
    Emergency Room Services for Treatment of Illness or Injury ..................................................................................................32
    Family Planning Benefits............................................................................................................................................................32
    Home Health Care Benefits ........................................................................................................................................................32
    Home Infusion/Home Injectable Therapy Benefits....................................................................................................................33
    Hemophilia home infusion products and Services .....................................................................................................................33
    Hospice Program Benefits...........................................................................................................................................................34
    Hospital Benefits (Facility Services) ..........................................................................................................................................36
    Medical Treatment of Teeth, Gums, Jaw Joints or Jaw Bones Benefits....................................................................................37
    Mental Health Services ...............................................................................................................................................................37


                                                                                              5
TABLE OF CONTENTS
    Orthotics Benefits........................................................................................................................................................................38
    Outpatient Prescription Drugs Benefits ......................................................................................................................................38
    Outpatient X-ray, Pathology and Laboratory Benefits...............................................................................................................42
    PKU Related Formulas and Special Food Products Benefits ....................................................................................................42
    Podiatric Benefits ........................................................................................................................................................................43
    Pregnancy and Maternity Care Benefits .....................................................................................................................................43
    Preventive Health Benefits..........................................................................................................................................................43
    Professional (Physician) Benefits ...............................................................................................................................................43
    Prosthetic Appliances Benefits ...................................................................................................................................................44
    Radiological Procedures Benefits (Requiring Prior Authorization) ..........................................................................................44
    Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) .............................................................................44
    Skilled Nursing Facility Benefits................................................................................................................................................45
    Speech Therapy Benefits.............................................................................................................................................................45
    Transplant Benefits – Cornea, Kidney or Skin...........................................................................................................................45
    Transplant Benefits - Special ......................................................................................................................................................45
PRINCIPAL LIMITATIONS, EXCEPTIONS, EXCLUSIONS AND REDUCTIONS .................................................................................... 46
    General Exclusions......................................................................................................................................................................46
    Medical Necessity Exclusion ......................................................................................................................................................49
    Limitations for Duplicate Coverage............................................................................................................................................49
    Exception for Other Coverage ....................................................................................................................................................50
    Claims Review ............................................................................................................................................................................50
    Reductions – Third Party Liability..............................................................................................................................................50
TERMINATION OF BENEFITS AND CANCELLATION PROVISIONS .................................................................................................. 51
    Termination of Benefits ..............................................................................................................................................................51
    Extension of Benefits ..................................................................................................................................................................52
    Coordination of Benefits .............................................................................................................................................................52
GROUP CONTINUATION COVERAGE AND INDIVIDUAL CONVERSION PLAN ................................................................................. 53
    Continuation of Group Coverage................................................................................................................................................53
    Availability of the Claims Administrator Individual Plans........................................................................................................55
    Individual Conversion Plan.........................................................................................................................................................55
GENERAL PROVISIONS ................................................................................................................................................................ 56
    Liability of Participants in the Event of Non-Payment by the Claims Administrator...............................................................56
    Non-Assignability .......................................................................................................................................................................56
    Plan Interpretation .......................................................................................................................................................................56
    Confidentiality of Personal and Health Information ..................................................................................................................56
    Access to Information .................................................................................................................................................................56
    Independent Contractors .............................................................................................................................................................57
CUSTOMER SERVICE ................................................................................................................................................................. 57
SETTLEMENT OF DISPUTES ....................................................................................................................................................... 57
DEFINITIONS ............................................................................................................................................................................... 57
    Plan Provider Definitions ............................................................................................................................................................57
    All Other Definitions...................................................................................................................................................................59
SUPPLEMENT A – SUBSTANCE ABUSE CONDITION BENEFITS ..................................................................................................... 65
SUPPLEMENT B – HEARING AID SERVICES BENEFITS ................................................................................................................. 67




                                                                                               6
This Benefit Booklet constitutes only a summary of the health Plan. The health Plan document must be consulted to de-
termine the exact terms and conditions of coverage.
The plan document 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 Claims Administrator plans.
Be sure you understand the Benefits of this Plan before Services are received.


                                                             NOTICE
Please read this Benefit Booklet carefully to be sure you understand the Benefits, exclusions and general provisions. It is your
responsibility to keep informed about any changes in your health coverage.
Should you have any questions regarding your Claims Administrator health Plan, see your Employer or contact any of the
Claims Administrator offices listed on the last page of this booklet.


                                                          IMPORTANT
No Member has the right to receive the Benefits of this Plan for Services or supplies furnished following termination of cover-
age, except as specifically provided under the Extension of Benefits 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 Plan.
Benefits may be modified during the term of this Plan as specifically provided under the terms of the plan document 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.

Plan Administrator and Plan Sponsor
The Employer is the Plan Administrator and Plan Sponsor.
The Plan Administrator shall retain the authority to delegate its officers and Employees such responsibilities that are imposed by
the terms of the Plan s together with authority to control and manage the operation of the Benefit Plan.
The designated party, that sets up a healthcare plan for the benefit of the Employer’s Employees. The responsibilities of the Plan
Sponsor include determining membership parameters, investment choices and, providing contribution payment.
Program Administrator
The CSAC Excess Insurance Authority is the Program Administrator. The Authority shall have the duty to interpret and con-
strue the Memorandum of Understanding with regard to overall administration of the Program.
Claims Administrator
Blue Shield of California has been appointed the Claims Administrator. Blue Shield of California processes and reviews the
claims submitted under this Plan.
Blue Shield of California provides administrative claims payment services only and does not assume any financial risk or obliga-
tion with respect to claims.
Each Member Entity which has established a Benefit Plan for its Employees and are signatory to the Memorandum of Under-
standing shall have the duty and authority to interpret and construe the Benefit Plan it has established on behalf of the Member
Entity’s Employees subject to the Memorandum with the Authority.

Note: The following Summary of Benefits contains the Benefits and applicable Co-
payments of your Plan. The Summary of Benefits represents only a brief descrip-
tion of the Benefits. Please read this booklet carefully for a complete description of
provisions, benefits and exclusions of the Plan.



                                                                 7
             HDHP Preferred Savings Plan Summary of Benefits

Note: See the end of this Summary of Benefits for important benefit footnotes.
Summary of Benefits                                                                       Preferred Savings Plan
      Individual Coverage Calendar Year
                  Deductible1                                           Deductible Responsibility
           (Medical Plan Deductible)
                                                                Services by Preferred,       Services by Non-Preferred
                                                               Participating, and Other        and Non-Participating
                                                                       Providers                     Providers
Calendar Year Deductible                                                        $1,500 per Member


       Family Coverage Calendar Year
                Deductible1                                             Deductible Responsibility
         (Medical Plan Deductible)
                                                               Services by Preferred,        Services by Non-Preferred
                                                              Participating, and Other         and Non-Participating
                                                                      Providers                      Providers
Calendar Year Deductible                                                       $3,000 per Family2


Individual Coverage Member Maximum per                              Member Maximum Calendar Year
Calendar Year Out-of-Pocket Responsibility3                          Out-of-Pocket Responsibility
                                                                    Services by any combination of Preferred,
                                                                Participating, Other Providers, Non-Preferred and
                                                                           Non-Participating Providers
Calendar Year Out-Of-Pocket Maximum                                             $4,500 per Member


   Family Coverage Family Maximum per                                Family Maximum Calendar Year
Calendar Year Out-of-Pocket Responsibility3                           Out-of-Pocket Responsibility
                                                                    Services by any combination of Preferred,
                                                                Participating, Other Providers, Non-Preferred and
                                                                           Non-Participating Providers
Calendar Year Out-Of-Pocket Maximum                                              $9,000 per Family


    Member Maximum Lifetime Benefits                          Maximum Claims Administrator Payment
                                                               Services by Preferred,        Services by Non-Preferred
                                                              Participating, and Other         and Non-Participating
                                                                      Providers                      Providers
Lifetime Benefit Maximum                                                          No maximum


                                            Reduced Payment(s)
Reduced Payment(s) for Failure to Use the Benefits Management Program
Refer to the Benefits Management Program section for any reduced payments which may apply.




                                                          8
                            Benefit                                                 Member Copayment4
                                                                     Services by Preferred,            Services by
                                                                    Participating, and Other    Non-Preferred and Non-
                                                                           Providers4           Participating Providers5
Acupuncture Benefits
Acupuncture Covered Services up to a Benefit maximum of 12          20%6                       20%
visits per Member per Calendar Year. Services by Doctors of         Maximum Benefit payment    Maximum Benefit payment
Medicine and certified acupuncturists.                              up to $50 per visit        up to $50 per visit
Allergy Testing and Treatment Benefits
Allergy serum purchased separately for treatment                    20%                        40%
Office visits (includes visits for allergy serum injections)        20%                        40%
Ambulance Benefits
Emergency or authorized transport                                   20%                        20%
Ambulatory Surgery Center Benefits
Outpatient surgery performed at an Ambulatory Surgery Cen-          20%                        40% of up to $350 per day
ter
(See Non-Preferred payment example below)
  Example: 1 day in the Ambulatory Surgery Center,
  up to the $350 per day Allowable Amount
  times (x)
  40% Participant contribution=Participant payment of up to
$140
Note: Participating Ambulatory Surgery Centers may not be
available in all areas. Outpatient ambulatory surgery Services
may also be obtained from a Hospital or an ambulatory surgery
center that is affiliated with a Hospital. Ambulatory surgery
Services obtained from a Hospital or Hospital affiliated ambu-
latory surgery center will be paid at the Preferred or Non-
Preferred level as specified under Hospital Benefits (Facility
Services) in this Summary of Benefits.
Bariatric Surgery Benefits
All bariatric surgery Services must be prior authorized, in writ-
                                                                                                               
ing, from the Claims Administrator's Medical Director. Prior
authorization is required for all Members.
Hospital Inpatient Services                                         20%                        40% of up to $600 per day
Hospital Outpatient Services                                        20%                        40% of up to $350 per day
Physician Services                                                  20%                        40%
Chiropractic Benefits
Chiropractic Services                                               20%                        Not covered7
Services provided by a chiropractor up to a combined Benefit
maximum with Outpatient Rehabilitation Services of 26 visits
per Member per Calendar Year.
Clinical Trial for Cancer Benefits
Clinical trial for cancer Services                                  You pay nothing            You pay nothing
Covered Services for Members who have been accepted into
an approved clinical trial for cancer when prior authorized.
Note: Services for routine patient care will be paid on the
same basis and at the same Benefit levels as other covered Ser-
vices shown in this Summary of Benefits.




                                                                9
                            Benefit                                                Member Copayment4
                                                                       Services by Preferred,            Services by
                                                                      Participating, and Other    Non-Preferred and Non-
                                                                             Providers4           Participating Providers5
Diabetes Care Benefits
Devices, equipment and supplies                                       20%                        40%
Diabetes self-management training provided by a Physician in          20%                        40%
an office setting
Diabetes self-management training provided by a registered            20%                        40%
dietician or registered nurse who are certified diabetes educa-
tors
Dialysis Center Benefits8
Dialysis Services                                                     20%                        40% of up to $300 per day
Note: Dialysis Services may also be obtained from a Hospital.
Dialysis Services obtained from a Hospital will be paid at the
Preferred or Non-Preferred level as specified under Hospital
Benefits (Facility Services) of this Summary of Benefits.
Durable Medical Equipment Benefits
Durable Medical Equipment                                             20%                        40%
Emergency Room Benefits
Emergency room Physician Services                                     20%                        20%
Emergency room Services not resulting in admission                    20%                        20%
Emergency room Services resulting in admission                        20%                        20%9
(Billed as part of Inpatient Hospital Services)
Family Planning Benefits
Note: Copayments listed in this section are for Outpatient
Physician Services only. If Services are performed at a facility
(Hospital, Ambulatory Surgery Center, etc.), the facility Co-
payment listed under the appropriate facility Benefit in this
Summary of Benefits will also apply.
Counseling and consulting                                             20%                        40%
Diagnosis and treatment of cause of Infertility                       50%                        Not covered10
Diaphragm fitting procedure                                           20%                        40%
Elective abortion                                                     20%                        40%
Injectable contraceptives when administered by a Physician            20%                        40%
Insertion and/or removal of intrauterine device (IUD)                 20%                        Not covered10
Intrauterine device (IUD)                                             20%                        Not covered10
Physician office visits for diaphragm fitting or injectable con-      20%                        40%
traceptives
Tubal ligation                                                        20%                        40%
In an Inpatient facility, this Copayment is billed as part of In-
patient Hospital Services for a delivery/abdominal surgery
Vasectomy                                                             20%                        40%
Home Health Care Benefits
Home health care agency Services, including home visits by a          20%                        Not covered11
nurse, home health aide, medical social worker, physical thera-
pist, speech therapist, or occupational therapist for up to a total
of 100 visits by home health care agency providers per Mem-
ber per Calendar Year
Medical supplies and laboratory Services to the extent the            20%                        Not covered11
Benefits would have been provided had the Member remained
in the Hospital or Skilled Nursing Facility



                                                                 10
                         Benefit                                             Member Copayment4
                                                                 Services by Preferred,            Services by
                                                                Participating, and Other    Non-Preferred and Non-
                                                                       Providers4           Participating Providers5
Home Infusion/Home Injectable Therapy Benefits
Hemophilia home infusion Services provided by a Hemophilia      20%                        Not covered
Infusion Provider and prior authorized by the Claims Adminis-
trator
Home infusion/home intravenous injectable therapy provided      20%                        Not covered11
by a Home Infusion Agency (Home infusion agency visits are
not subject to the visit limitation under Home Health Care
Benefits.)
Note: Home non-intravenous self-administered injectable
drugs are covered under the Outpatient Prescription Drug
Benefit.
Home visits by an infusion nurse (Home infusion agency nurs-    20%                        Not covered11
ing visits are not subject to the Home Health Care Calendar
Year visit limitation.)
Hospice Program Benefits
Covered Services for Members who have been accepted into
an approved Hospice Program
All Hospice Program Benefits must be prior authorized by the
Claims Administrator and must be received from a Participat-
ing Hospice Agency.
24-hour Continuous Home Care                                    20%                        Not covered12
General Inpatient care                                          20%                        Not covered12
Inpatient Respite Care                                          You pay nothing            Not covered12
Pre-hospice consultation                                        You pay nothing            Not covered12
Routine home care                                               You pay nothing            Not covered12




                                                           11
                           Benefit                                               Member Copayment4
                                                                     Services by Preferred,            Services by
                                                                    Participating, and Other    Non-Preferred and Non-
                                                                           Providers4           Participating Providers5
Hospital Benefits (Facility Services)
Inpatient Emergency Facility Services                               20%                        20%13
Inpatient non-Emergency Facility Services                           20%                        40% of up to $600 per day
(See Non-Preferred payment example below)
 Example: 1 day in the Hospital,
 up to the $600 per day Allowable Amount
 times (x)
 40% Participant contribution=Participant payment of up to
$240
All bariatric surgery Services must be prior authorized in writ-
ing.
Inpatient Medically Necessary skilled nursing Services includ-      20%                        40% of up to $600 per day
ing Subacute Care14
Inpatient Services to treat acute medical complications of de-      20%                        40% of up to $600 per day
toxification
Outpatient dialysis Services8                                       20%                        40% of up to $300 per day13
(See Non-Preferred payment example below)
 Example: 1 day in the Hospital,
 up to the $300 per day Allowable Amount
 times (x)
 40% Participant contribution=Participant payment of up to
$120
Outpatient Services for surgery and necessary supplies              20%                        40% of up to $350 per day13
(See Non-Preferred payment example below)
 Example: 1 day in the Hospital,
 up to the $350 Allowable Amount
 times (x)
 40% Participant contribution=Participant payment of up to
$140
Outpatient Services for treatment of illness or injury, radiation   20%                        40% of up to $350 per day13
therapy, chemotherapy and necessary supplies
(See Non-Preferred payment example below)
 Example: 1 day in the Hospital,
 up to the $350 per day Allowable Amount
 times (x)
 40% Participant contribution=Participant payment of up to
$140




                                                               12
                           Benefit                                                Member Copayment4
                                                                     Services by Preferred,            Services by
                                                                    Participating, and Other    Non-Preferred and Non-
                                                                           Providers4           Participating Providers5
Medical Treatment of the Teeth, Gums, Jaw Joints or Jaw
Bones Benefits
Treatment of gum tumors, damaged natural teeth resulting
from Accidental Injury, TMJ as specifically stated and orthog-
nathic surgery for skeletal deformity (be sure to read the Prin-
cipal Benefits and Coverages (Covered Services) section for a
complete description)
Inpatient Hospital Services                                         20%                        40% of up to $600 per day13
Office location                                                     20%                        40%
Outpatient department of a Hospital                                 20%                        40% of up to $350 per day13
Mental Health Benefits14
Inpatient Hospital Services15                                       20%                        40% of up to $600 per day16
Inpatient Professional (Physician) Services                         20%                        40%
Outpatient Mental Health Services, Intensive Outpatient Care        20%17                      40%17
and Outpatient electroconvulsive therapy (ECT)16
Outpatient Partial Hospitalization16                                20% per episode18          40% per episode of up to
                                                                                               $350 per day18
Psychological testing                                               You pay nothing            40%
Orthotics Benefits
Office visits                                                       20%                        40%
Orthotic equipment and devices                                      20%                        40%
                                                                                                     Non-Participating
Outpatient Prescription Drug Benefits19                             Participating Pharmacy
                                                                                                      Pharmacy20, 21
Retail Prescriptions
Formulary Generic Drugs                                             20% per prescription       20% per prescription
Formulary Brand Name Drugs22                                        20% per prescription       20% per prescription
Non-Formulary Brand Name Drugs                                      20% per prescription       20% per prescription
Smoking cessation Drugs                                             20% per prescription       Not covered
Mail Service Prescriptions
Formulary Generic Drugs                                             20% per prescription       Not covered
Formulary Brand Name Drugs23                                        20% per prescription       Not covered
Non-Formulary Brand Name Drugs                                      20% per prescription       Not covered
Specialty Pharmacies
Specialty Drugs                                                     20% up to a maximum of     Not covered
                                                                    $100 out-of-pocket co-
                                                                    payment maximum per
                                                                    prescription




                                                               13
                           Benefit                                               Member Copayment4
                                                                     Services by Preferred,            Services by
                                                                    Participating, and Other    Non-Preferred and Non-
                                                                           Providers4           Participating Providers5
Outpatient X-ray, Pathology and Laboratory Benefits
Mammography and Papanicolaou test                                   You pay nothing            40%
Outpatient X-ray, pathology and laboratory                          You pay nothing            40%23
PKU Related Formulas and Special Food Products Benefits
PKU Related Formulas and Special Food Products Benefits             20%                        Not covered11
The above Services must be prior authorized by the Claims
Administrator.
Podiatric Benefits
Podiatric Services provided by a licensed doctor of podiatric       20%                        40%
medicine
Pregnancy and Maternity Care Benefits
Note: Routine newborn circumcision is only covered as de-
scribed in the Principal Benefits and Coverages (Covered Ser-
vices) section. When covered, Services will pay as any other
surgery as noted in this Summary of Benefits.
All necessary Inpatient Hospital Services for normal delivery,      20%                        40% of up to $600 per day13
Cesarean section, and complications of pregnancy
Prenatal and postnatal Physician office visits, including prena-    20%                        40%13
tal diagnosis of genetic disorders of the fetus by means of di-
agnostic procedures in cases of high-risk pregnancy
Preventive Health Benefits
Annual routine gynecological office visit, including the gyne-      You pay nothing            40%
cological examination office visit, routine mammography, rou-       (Deductible waived)
tine Papanicolaou (Pap) test or other FDA approved cervical
cancer screening test, human papillomavirus (HPV) screening
tests.
Annual routine physical examination office visit, including the     You pay nothing            40%
physical examination office visit, routine eye/ear screening for    (Deductible waived)
Members through age 18 and pediatric and adult immuniza-
tions and the immunization agent.
Colorectal cancer screening                                         You pay nothing            40%
                                                                    (Deductible waived)
Osteoporosis screening                                              You pay nothing            40%
                                                                    (Deductible waived)
Routine laboratory Services including well baby laboratory          You pay nothing            40%
Services                                                            (Deductible waived)
Well baby office visits, including well baby examination office     You pay nothing            40%
visit, pediatric immunizations and the immunization agent,          (Deductible waived)
well baby vision and hearing screening
Professional (Physician) Benefits
Inpatient Physician Services                                        20%                        40%
Physician home visits                                               20%                        Not covered24
Physician office visits                                             20%                        40%
Services with the office visit                                      20%                        40%




                                                               14
                           Benefit                                                Member Copayment4
                                                                      Services by Preferred,            Services by
                                                                     Participating, and Other    Non-Preferred and Non-
                                                                            Providers4           Participating Providers5
Prosthetic Appliances Benefits
Office visits                                                        20%                        40%
Prosthetic equipment and devices (except those provided to           20%                        40%
restore and achieve symmetry incident to a mastectomy, which
are covered under Ambulatory Surgery Center Benefits, Hospi-
tal Benefits (Facility Services), and Professional (Physician)
Benefits in the Principal Benefits and Coverages (Covered
Services) section, and specified devices following a laryngec-
tomy, which are covered under Physician Services surgical
Benefits)
Radiological Procedures Benefits (Requiring Prior Au-
thorization)
Outpatient, non-emergency radiological procedures including          You pay nothing23          40%23
CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic
procedures utilizing nuclear medicine
Note: The Claims Administrator requires prior authorization
for all these Services.
Rehabilitation Benefits (Physical, Occupational and Respi-
ratory Therapy)
Rehabilitation Services by a physical, occupational, or respira-
tory therapist in the following settings:
Office location                                                      20%25                      Not covered26
Outpatient department of a Hospital                                  20%25                      Not covered26
Note: Outpatient Rehabilitation Services are limited to a com-
bined visit maximum with chiropractic Services of 26 visits per
Member per Calendar Year
Rehabilitation unit of a Hospital for Medically Necessary days       20%                        40% of up to $600 per day
In an Inpatient facility, this Copayment is billed as part of In-
patient Hospital Services
Skilled Nursing Facility rehabilitation unit for Medically Nec-      20%27                      20%27
essary days
Skilled Nursing Facility Benefits
Services by a free-standing Skilled Nursing Facility14               20%27                      20%27
Speech Therapy Benefits
Note: All Outpatient Speech Therapy Services must be prior
authorized by the Claims Administrator.
Speech Therapy Services by a licensed speech pathologist or
certified speech therapist in the following settings:
Office location                                                      20%28                      40%
Outpatient department of a Hospital                                  20%28                      40% of up to $350 per day
Rehabilitation unit of a Hospital for Medically Necessary days       20%                        40% of up to $600 per day
In an Inpatient facility, this Copayment is billed as part of In-
patient Hospital Services
Skilled Nursing Facility rehabilitation unit for Medically Nec-      20%27                      20%27
essary days




                                                                15
                          Benefit                                              Member Copayment4
                                                                   Services by Preferred,            Services by
                                                                  Participating, and Other    Non-Preferred and Non-
                                                                         Providers4           Participating Providers5
Transplant Benefits - Cornea, Kidney or Skin
Organ Transplants for transplant of a cornea, kidney or skin
Hospital Services                                                 20%                        40% of up to $600 per day
Professional (Physician) Services                                 20%                        40%
Transplant Benefits – Special29
Note: The Claims Administrator requires prior written au-
thorization from the Claims Administrator's Medical Director
for all Special Transplant Services. Also, all Services must be
provided at a Special Transplant Facility designated by the
Claims Administrator.
Special Transplant Benefits for transplant of human heart,
lung, heart and lung in combination, human bone marrow
transplants, pediatric human small bowel transplants, pediatric
and adult human small bowel and liver transplants in combina-
tion, and Services to obtain the human transplant material
Facility Services in a Special Transplant Facility                20%                        Not covered
Professional (Physician) Services                                 20%                        Not covered




                                                             16
Summary of Benefits
Footnotes
1
     The Calendar Year Deductible does not apply to the Services listed below:
     Preventive Health Benefits from Preferred Providers.
     Participating Physician office visits are subject to the Calendar Year Deductible.
     Note: Payments applied to your Calendar Year Deductible accrue towards the maximum Calendar Year out-of-pocket
     responsibility.
2
     Before benefits will be provided for covered Services to any and all covered Members, the Calendar Year Family Cover-
     age Deductible must be satisfied for those Services to which it applies. This Deductible must be made up of charges
     covered by the Plan and must be satisfied once during each Calendar Year. For those Services to which the Family Cov-
     erage Deductible applies, charges Incurred by one or all of the covered Members in combination will be used to calculate
     the Calendar Year Family Coverage Deductible.
3
     Unless otherwise specified, Copayments are calculated based on the Allowable Amount.
4
     Other Providers are not Preferred Providers and so for Services by Other Providers you are responsible for all charges
     above the Allowable Amount. Other Providers include ambulance companies, nursing homes and certain labs (for a
     complete list of Other Providers see the Definitions section).
5
     For Services by Non-Preferred and Non-Participating Providers you are responsible for all charges above the Allowable
     Amount.
6
     For Services by certificated acupuncturists, which are Other Providers, you are responsible for all charges above the Al-
     lowable Amount.
7
     No Benefits are provided for chiropractic Services by Non-Preferred Providers
8
     Prior authorization by the Plan is required for all dialysis Services.
9
     For emergency room Services directly resulting in admission as an Inpatient to a Non-Preferred Hospital which the
     Claims Administrator determines are not emergencies, your Copayment will be the Non-Preferred Hospital Outpatient
     Services Copayment.
10
     No benefits are provided for Family Planning Services for diagnosis and treatment of cause of Infertility and IUDs in-
     cluding insertion and removal of IUD by Non-Preferred or Non-Participating Providers.
11
     Services by Non-Participating Home Health Care/Home Infusion Agencies are not covered unless prior authorized by the
     Plan. When authorized by the Plan, these Non-Participating Agencies will be reimbursed at a rate determined by the
     Plan and the agency and your Copayment will be the Participating Agency Copayment.
12
     Services by Non-Participating Hospice Agencies are not covered unless prior authorized by the Plan. When authorized
     by the Plan, these Non-Participating Agencies will be reimbursed at a rate determined by the Plan and the agency and
     your Copayment will be the Participating Agency Copayment.
13
     For Emergency Services by Non-Preferred Providers, your Copayment will be the Preferred Provider Copayment.
14
     Skilled nursing Services are limited to 100 days during any Calendar Year except when received through a Hospice Pro-
     gram provided by a Participating Hospice Agency. This 100-day maximum for skilled nursing Services is a combined
     maximum between Hospital and Skilled Nursing Facilities.
15
     No benefits are provided for Substance Abuse Conditions, unless substance abuse coverage is selected as an optional
     Benefit by your Employer. Note: Inpatient Services which are Medically Necessary to treat the acute medical complica-
     tions of detoxification are covered as part of the medical Benefits and are not considered to be treatment of the Substance
     Abuse Condition itself.
16
     All Inpatient Mental Health Services, Outpatient Partial Hospitalization, Intensive Outpatient Care and Outpatient elec-
     troconvulsive therapy Services (except for Emergency and urgent Services) must be prior authorized by the Claims Ad-
     ministrator
17
     This Copayment includes both Outpatient facility and Professional (Physician) Services.
18
     For Outpatient Partial Hospitalization Services, an episode of care is the date from which the patient is admitted to the
     Partial Hospitalization Program to the date the patient is discharged or leaves the Partial Hospitalization Program. Any
     Services received between these two dates would constitute the episode of care. If the patient needs to be readmitted at a
     later date, this would constitute another episode of care.
19
     This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal
     government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is
     creditable, you do not have to enroll in Medicare Part D while you maintain this coverage; however, you should be aware
     that if you have a subsequent break in this coverage of 63 days or more before enrolling in Medicare Part D you could be
     subject to payment of higher Part D premiums.

                                                               17
20
     To obtain prescription Drugs at a Non-Participating Pharmacy, the Participant must first pay all charges for the prescrip-
     tion and submit a completed Prescription Drug Claim Form for reimbursement. After the Calendar Year Deductible
     amount has been satisfied, the Participant will be reimbursed as shown on the Summary of Benefits.
21
     Outpatient Prescription Drug Copayments for covered Drugs obtained from Non-Participating Pharmacies will accrue to
     the Preferred Provider maximum Calendar Year out-of-pocket responsibility.
22
     For diaphragms, the Formulary Brand Name Copayment applies.
23
     Your Copayment will be assessed per provider per date of service.
24
     No benefits are provided for Professional (Physician) home visits by Non-Preferred or Non-Participating Providers.
25
     For Services by certified occupational therapists and certified respiratory therapists, which are Other Providers, you are
     responsible for all charges above the Allowable Amount.
26
     No Benefits are provided for Outpatient Rehabilitation Services from Non-Preferred Providers.
27
     For Services by free-standing Skilled Nursing Facilities (nursing homes), which are Other Providers, you are responsible
     for all charges above the Allowable Amount.
28
     For Services by licensed speech therapists, which are Other Providers, you are responsible for all charges above the Al-
     lowable Amount.
29
     Special Transplant Benefits are limited to the procedures listed in the Principal Benefits and Coverages (Covered Ser-
     vices) section. See the Transplant Benefits - Special section for information on Services and requirements.




                                                              18
WHAT IS A HEALTH SAVINGS ACCOUNT                                       In order to receive the highest level of Benefits, you should
                                                                       assure that your provider is a Preferred Provider (see the
(HSA)?                                                                 “Claims Administrator Preferred Providers” section).
An HSA is a tax-advantaged personal savings or investment              You are responsible for following the provisions shown in
account intended for payment of medical expenses, including            the “Benefits Management Program” section of this booklet,
Plan Deductibles and Copayments, as well as some medical               including:
expenses not covered by your health Plan. Contributions to a
qualified HSA are Deductible from gross income for tax pur-            1.   You or your Physician must obtain the Claims Adminis-
poses and can be used tax-free to pay for qualified medical                 trator approval at least 5 working days before Hospital
expenses. HSA funds may also be saved on a tax-deferred                     or Skilled Nursing Facility admissions for all non-
basis for the future.                                                       Emergency Inpatient Hospital or Skilled Nursing Facility
                                                                            Services. (See the “Claims Administrator Preferred Pro-
                                                                            viders” section for information.)
HOW A HEALTH SAVINGS ACCOUNT
                                                                       2.   You or your Physician must notify Claims Administrator
WORKS                                                                       within 24 hours or by the end of the first business day
An HSA is very similar to the flexible spending accounts                    following Emergency admissions, or as soon as it is rea-
currently offered by some employers. If you qualify for and                 sonably possible to do so.
set up an HSA with a qualified institution, the money depos-           3.   You or your Physician must obtain prior authorization in
ited will be tax-deductible and can be used tax-free to reim-               order to determine if contemplated services are covered.
burse you for many medical expenses. So, instead of using                   See “Prior Authorization” in the “Benefits Management
taxed income for medical care as you satisfy your Deducti-                  Program” section for a listing of services requiring prior
ble, you may use 100% of every dollar invested (plus inter-                 authorization.
est). And, as with an Individual Retirement Account, any
amounts you do not use (or withdraw with penalty) can grow.            Failure to meet these responsibilities may result in your in-
Your principal and your returns may be rolled over from year           curring a substantial financial liability. Some services may
to year to provide you with tax-deferred savings for future            not be covered unless prior review and other requirements
medical or other uses.                                                 are met.
Please note that the Claims Administrator does not offer               Note: The Claims Administrator will render a decision on all
HSAs itself, and only offers high deductible health plans.             requests for prior authorization review within 5 business days
                                                                       from receipt of the request. The treating provider will be
If you are interested in learning more about Health Savings            notified of the decision within 24 hours followed by written
Accounts, eligibility and the law's current provisions, ask            notice to the provider and Participant within 2 business days
your benefits administrator and consult with a financial advi-         of the decision. For urgent services in situations in which the
sor.                                                                   routine decision making process might seriously jeopardize
                                                                       the life or health of a Member or when the Member is experi-
INTRODUCTION TO THE CLAIMS                                             encing severe pain, the Claims Administrator will respond as
ADMINISTRATOR PREFERRED SAVINGS                                        soon as possible to accommodate the Member’s condition
                                                                       not to exceed 72 hours from receipt of the request.
PLAN
                                                                       PLEASE READ THE FOLLOWING INFORMATION SO
Benefits of this Plan differ substantially from traditional            YOU WILL KNOW FROM WHOM OR WHAT GROUP
Claims Administrator plans. If you have questions about                OF PROVIDERS HEALTH CARE MAY BE OBTAINED.
your Benefits, contact the Claims Administrator before Hos-
pital or medical Services are received.
                                                                       CLAIMS ADMINISTRATOR PREFERRED
This Plan is designed to reduce the cost of health care to you,        PROVIDERS
the Participant. In order to reduce your costs, greater respon-
sibility is placed on you.                                             The Claims Administrator Preferred Plan is specifically de-
                                                                       signed for you to use Claims Administrator Preferred Provid-
You should read your booklet carefully. Your booklet tells
                                                                       ers. Preferred Providers include certain Physicians, Hospi-
you which services are covered by your health Plan and
                                                                       tals, Alternate Care Services Providers, and other Providers.
which are excluded. It also lists your Copayment and De-
                                                                       Preferred Providers are listed in the Preferred Provider direc-
ductible responsibilities.
                                                                       tories. To determine whether a provider is a Preferred Pro-
When you need health care, present your Claims Administra-             vider, consult the Preferred Provider Directory. You may
tor I.D. card to your Physician, Hospital, or other licensed           also verify this information by accessing the Claims Admin-
healthcare provider. Your I.D. card has your Participant and           istrator’s Internet site located at http://www.blueshieldca.com
group numbers on it. Be sure to include these numbers on all           or by calling Customer Service at the telephone number pro-
claims you submit to the Claims Administrator.                         vided at the back of this booklet. Note: A Preferred Pro-
                                                                       vider’s status may change. It is your obligation to verify


                                                                  19
whether the Physician, Hospital or Alternate Care Services              from birth to 36 months of age; or who have received au-
provider you choose is a Preferred Provider, in case there              thorization from a now-terminated provider for surgery or
have been any changes since your Preferred Provider Direc-              another procedure as part of a documented course of treat-
tory was published.                                                     ment can request completion of care in certain situations with
                                                                        a provider who is leaving the Claims Administrator provider
Note: In some instances services are covered only if ren-
                                                                        network. Contact Customer Service to receive information
dered by a Preferred Provider. Using a Non-Preferred Pro-
                                                                        regarding eligibility criteria and the policy and procedure for
vider could result in lower or no payment by the Claims Ad-
                                                                        requesting continuity of care from a terminated provider.
ministrator for services.
Claims Administrator Preferred Providers agree to accept the            FINANCIAL RESPONSIBILITY FOR CONTINUITY OF
Claims Administrator's payment, plus your payment of any                CARE SERVICES
applicable Deductibles, Copayments, or amounts in excess of
                                                                        If a Participant is entitled to receive Services from a termi-
specified Benefit maximums as payment-in-full for covered
                                                                        nated provider under the preceding Continuity of Care provi-
Services, except as provided under the Exception for Other
                                                                        sion, the responsibility of the Participant to that provider for
Coverage provision and in the Reductions section regarding
                                                                        Services rendered under the Continuity of Care provision
Third Party Liability. This is not true of Non-Preferred Pro-
                                                                        shall be no greater than for the same Services rendered by a
viders.
                                                                        Preferred Provider in the same geographic area.
You are not responsible to Participating and Preferred Pro-
viders for payment for covered Services, except for the Co-             SUBMITTING A CLAIM FORM
payments and amounts in excess of specified Benefit maxi-               Preferred Providers submit claims for payment after their
mums, and except as provided under the Exception for Other              Services have been received. You or your Non-Preferred
Coverage provision and in the Reductions section regarding              Providers also submit claims for payment after Services have
Third Party Liability.                                                  been received.
The Claims Administrator contracts with Hospitals and Phy-              You are paid directly by the Claims Administrator if Services
sicians to provide Services to Members for specified rates.             are rendered by a Non-Preferred Provider, except in the case
This contractual arrangement may include incentives to man-             of Emergency Services. Requests for payment must be sub-
age all services provided to Members in an appropriate man-             mitted to the Claims Administrator within 1 year after the
ner consistent with the contract. If you want to know more              month Services were provided. Special claim forms are not
about this payment system, contact Customer Service at the              necessary, but each claim submission must contain your
number provided on the back page of this booklet.                       name, home address, group contract number, Participant’s
If you go to a Non-Preferred Provider, the Claims Adminis-              number, a copy of the provider’s billing showing the Services
trator's payment for a Service by that Non-Preferred Provider           rendered, dates of treatment and the patient’s name. The
may be substantially less than the amount billed. You are               Claims Administrator will notify you of its determination
responsible for the difference between the amount the Claims            within 30 days after receipt of the claim.
Administrator pays and the amount billed by Non-Preferred               To submit a claim for payment, send a copy of your itemized
Providers. It is therefore to your advantage to obtain medical          bill, along with a completed the Claims Administrator Par-
and Hospital Services from Preferred Providers.                         ticipant’s Statement of Claim form to the Claims Administra-
Payment for Emergency Services rendered by a Physician or               tor service center listed on the last page of this booklet.
Hospital who is not a Preferred Provider will be based on the           Claim forms are available on the Claims Administrator’s
Allowable Amount but will be paid at the Preferred level of             Internet site located at http://www.blueshieldca.com or you
benefits. You are responsible for notifying the Claims Ad-              may call the Claims Administrator Customer Service at the
ministrator within 24 hours, or by the end of the first business        number provided on the back page of this booklet to ask for
day following emergency admission at a Non-Preferred Hos-               forms. If necessary, you may use a photocopy of the Claims
pital, or as soon as it is reasonably possible to do so.                Administrator claim form.
Directories of Claims Administrator Preferred Providers lo-             Be sure to send in a claim for all covered Services even if
cated in your area have been provided to you. Extra copies              you have not yet met your Calendar Year Deductible. The
are available from the Claims Administrator. If you do not              Claims Administrator will keep track of the Deductible for
have the directories, please contact the Claims Administrator           you. The Claims Administrator uses an Explanation of
immediately and request them at the telephone number listed             Benefits to describe how your claim was processed and to
on the last page of this booklet.                                       inform you of your financial responsibility.
CONTINUITY OF CARE BY A TERMINATED
PROVIDER                                                                ELIGIBILITY
Participants who are being treated for acute conditions, seri-          If you are an Employee, you are eligible for coverage as a
ous chronic conditions, pregnancies (including immediate                Participant the day following the date you complete the wait-
postpartum care), or terminal illness; or who are children              ing period established by your Employer. Your spouse or


                                                                   20
Domestic Partner and all your Dependent children are eligi-             Enrolled Dependent children who would normally lose their
ble at the same time.                                                   eligibility under this Plan solely because of age, but who are
                                                                        incapable of self-sustaining employment by reason of a
When you decline coverage for yourself or your Dependents
                                                                        physically or mentally disabling injury, illness, or condition,
during the initial enrollment period and later request enroll-
                                                                        may have their eligibility extended under the following con-
ment, you and your Dependents will be considered to be Late
                                                                        ditions: (1) the child must be chiefly dependent upon the
Enrollees. When Late Enrollees decline enrollment during
                                                                        Employee for support and maintenance, and (2) the Em-
the initial enrollment period, they will be eligible the earlier
                                                                        ployee must submit a Physician’s written certification of such
of 12 months from the date of the request for enrollment or at
                                                                        disabling condition. The Claims Administrator or the Em-
the Employer’s next Open Enrollment Period. The Claims
                                                                        ployer will notify you at least 90 days prior to the date the
Administrator will not consider applications for earlier effec-
                                                                        Dependent child would otherwise lose eligibility. You must
tive dates.
                                                                        submit the Physician’s written certification within 60 days of
You and your Dependents will not be considered to be Late               the request for such information by the Employer or by the
Enrollees if either you or your Dependents lose coverage                Claims Administrator. Proof of continuing disability and
under another employer health plan and you apply for cover-             dependency must be submitted by the Employee as requested
age under this Plan within 31 days of the date of loss of cov-          by the Claims Administrator but not more frequently than 2
erage. You will be required to furnish the Claims Adminis-              years after the initial certification and then annually thereaf-
trator written proof of the loss of coverage.                           ter.
Newborn infants of the Participant, spouse, or his or her Do-           The Employer must meet specified Employer eligibility, par-
mestic Partner will be eligible immediately after birth for the         ticipation and contribution requirements to be eligible for this
first 31 days. A child placed for adoption will be eligible             group Plan. See your Employer for further information.
immediately upon the date the Participant, spouse or Domes-
                                                                        Subject to the requirements described under the Continuation
tic Partner has the right to control the child’s health care.
                                                                        of Group Coverage provision in this booklet, if applicable, an
Enrollment requests for children who have been placed for
                                                                        Employee and his or her Dependents will be eligible to con-
adoption must be accompanied by evidence of the Partici-
                                                                        tinue group coverage under this Plan when coverage would
pant’s, spouse’s or Domestic Partner’s right to control the
                                                                        otherwise terminate.
child’s health care. Evidence of such control includes a
health facility minor release report, a medical authorization
form or a relinquishment form. In order to have coverage                EFFECTIVE DATE OF COVERAGE
continue beyond the first 31 days without lapse, an applica-
                                                                        Coverage will become effective for Employees and Depend-
tion must be submitted to and received by the Claims Admin-
                                                                        ents who enroll during the initial enrollment period at 12:01
istrator within 31 days from the date of birth or placement for
                                                                        a.m. Pacific Time on the eligibility date established by your
adoption of such Dependent.
                                                                        Employer.
A child acquired by legal guardianship will be eligible on the
                                                                        If, during the initial enrollment period, you have included
date of the court ordered guardianship, if an application is
                                                                        your eligible Dependents on your application to the Claims
submitted within 31 days of becoming eligible.
                                                                        Administrator, their coverage will be effective on the same
You may add newly acquired Dependents and yourself to the               date as yours. If application is made for Dependent coverage
Plan by submitting an application within 31 days from the               within 31 days after you become eligible, their effective date
date of acquisition of the Dependent:                                   of coverage will be the same as yours.
1.   to continue coverage of a newborn or child placed for              If you or your Dependent is a Late Enrollee, your coverage
     adoption;                                                          will become effective the earlier of 12 months from the date
                                                                        you made a written request for coverage or at the Employer’s
2.   to add a spouse after marriage or add a Domestic Partner           next Open Enrollment Period. The Claims Administrator
     after establishing a domestic partnership;                         will not consider applications for earlier effective dates.
3.   to add yourself and spouse following the birth of a new-           If you declined coverage for yourself and your Dependents
     born or placement of a child for adoption;                         during the initial enrollment period because you or your De-
4.   to add yourself and spouse after marriage;                         pendents were covered under another employer health plan,
                                                                        and you or your Dependents subsequently lost coverage un-
5.   to add yourself and your newborn or child placed for               der that plan, you will not be considered a Late Enrollee.
     adoption, following birth or placement for adoption.               Coverage for you and your Dependents under this Plan will
Coverage is never automatic; an application is always re-               become effective on the date of loss of coverage, provided
quired.                                                                 you enroll in this Plan within 31 days from the date of loss of
                                                                        coverage. You will be required to furnish the Claims Admin-
If both partners in a marriage or domestic partnership are              istrator written evidence of loss of coverage.
eligible to be Participants, children may be eligible and may
be enrolled as a Dependent of either parent, but not both.              If you declined enrollment during the initial enrollment pe-
                                                                        riod and subsequently acquire Dependents as a result of mar-


                                                                   21
riage, establishment of domestic partnership, birth, or place-          If this Plan provides Benefits within 60 days of the date of
ment for adoption, you may request enrollment for yourself              discontinuance of the previous group health plan that was in
and your Dependents within 31 days. The effective date of               effect with your Employer, you and all your Dependents who
enrollment for both you and your Dependents will depend on              were validly covered under the previous group health plan on
how you acquire your Dependent(s):                                      the date of discontinuance will be eligible under this Plan.
1.   For marriage or domestic partnership, the effective date
     will be the first day of the first month following receipt
     of your request for enrollment;
                                                                        MEDICAL CARE BENEFITS
2.   For birth, the effective date will be the date of birth;           The individual’s coverage will be effective as described in
                                                                        this booklet.
3.   For a child placed for adoption, the effective date will be
     the date the Participant, spouse, or Domestic Partner has          ANNUAL OPEN ENROLLMENT
     the right to control the child’s health care.
                                                                        An annual Open Enrollment Period will be available for
Once each Calendar Year, your Employer may designate a                  any Member or Dependent who failed to enroll:
time period as an annual Open Enrollment Period. During
                                                                        •   during the first period in which he or she was eligible
that time period, you and your Dependents may transfer from
                                                                            to enroll, or during any subsequent special enrollment
another health plan sponsored by your Employer to the Pre-
                                                                            period; or
ferred Plan. A completed enrollment form must be for-
warded to Claims Administrator within the Open Enrollment               •   during any previous annual Open Enrollment Period; or
Period. Enrollment becomes effective on the anniversary
date of this Plan following the annual Open Enrollment Pe-              •   within 31 days after the termination date, if the indi-
riod.                                                                       vidual was previously covered under the Plan but
                                                                            elected to terminate the coverage.
Any individual who becomes eligible at a time other than
during the annual Open Enrollment Period (e.g., newborn,                To qualify for enrollment during the annual Open Enroll-
child placed for adoption, child acquired by legal guardian-            ment Period, the Member or Dependent:
ship, new spouse or Domestic Partner, newly hired or newly              •   must meet the eligibility requirements described in the
transferred Employees) must complete an enrollment form                     Plan, including satisfaction of any applicable waiting
within 31 days of becoming eligible.                                        period; and
Coverage for a newborn child will become effective on the               •   may not be covered under an alternate medical expense
date of birth. Coverage for a child placed for adoption will                coverage offered by the Employer, unless the annual
become effective on the date the Participant, spouse or Do-                 Open Enrollment Period happens to coincide with a
mestic Partner has the right to control the child’s health care,            separate Open Enrollment Period established for cov-
following submission of evidence of such control (a health                  erage election.
facility minor release report, a medical authorization form or
a relinquishment form). In order to have coverage continue              The effective date for any qualified individual requesting
beyond the first 31 days without lapse, a written application           coverage during the annual Open Enrollment Period will be
must be submitted to and received by the Claims Administra-             the day immediately following the completion of the annual
tor within 31 days. A Dependent spouse becomes eligible on              Open Enrollment Period.
the date of marriage. A Domestic Partner becomes eligible
on the date a domestic partnership is established as set forth          SPECIAL ENROLLMENT EVENT
in the Definitions section of this booklet. A child acquired            If you or your Dependent request enrollment after the first
by legal guardianship will be eligible on the date of the court         period in which you or your Dependent were eligible to
ordered guardianship.                                                   enroll but during a special enrollment event due to a family
If a court has ordered that you provide coverage for your               status change (newborn, child placed for adoption, child
spouse, Domestic Partner or Dependent child under your                  acquired by legal guardianship, new spouse or Domestic
health benefit Plan, their coverage will become effective               Partner, newly hired or newly transferred Employees), you
within 31 days of presentation of a court order by the district         or your Dependent will be a special enrollee and will not be
attorney, or upon presentation of a court order or request by a         considered a Late Enrollee.
custodial party, as described in Section 3751.5 of the Family           If the Employer offers different Benefit options, a Benefit
Code.                                                                   option transfer may also be made on any contribution due
If you or your Dependents voluntarily discontinued coverage             date if your request is due to a special enrollment event and
under this Plan and later request reinstatement, you or your            you complete the appropriate enrollment form within the
Dependents will be covered the earlier of 12 months from the            time specified for a special enrollment event due to a family
date of request for reinstatement or at the Employer’s next             status change (newborn, child placed for adoption, child
Open Enrollment Period.                                                 acquired by legal guardianship, new spouse or Domestic
                                                                        Partner, newly hired or newly transferred Employees).


                                                                   22
If a request for contributory coverage is made more than 31            Remember that the second opinion visit is subject to all Plan
days after the date an individual is eligible but during a spe-        Benefit limitations and exclusions.
cial enrollment event due to a family status change, cover-
age for such individual will become effective as described             HEALTH EDUCATION
within in this section.
                                                                       AND HEALTH PROMOTION SERVICES
EFFECTIVE DATE FOR LATE ENROLLEES
                                                                       Health education and health promotion Services provided by
If a late enrollee requests coverage other than during an              the Claims Administrator’s Center for Health Improvement
annual Open Enrollment Period or special enrollment pe-                offer a variety of wellness resources including, but not lim-
riod, the effective date of coverage for the late enrollee will        ited to: a Participant newsletter and a prenatal health educa-
be the next plan anniversary date, provided on such date:              tion program.
•   the Member continues to meet the Plan’s definition of
    Member; and                                                        RETAIL-BASED HEALTH CLINICS
•   for Dependent coverage, the Dependents continue to                 Retail-based health clinics are Outpatient facilities, usually
    meet the Plan’s definition of Dependent.                           attached or adjacent to retail stores, pharmacies, etc., which
                                                                       provide limited, basic medical treatment for minor health
                                                                       issues. They are staffed by nurse practitioners under the di-
RENEWAL OF PLAN                                                        rection of a Physician and offer services on a walk-in basis.
The Claims Administrator will offer to renew the                       Covered Services received from retail-based health clinics
                                                                       will be paid on the same basis and at the same Benefit levels
Plan except in the following instances:                                as other covered Services shown in the Summary of Benefits.
1. non-payment of fees (see “Termination of                            Retail-based health clinics may be found in the Preferred
                                                                       Provider Directory or the Online Physician Directory located
   Benefits”);
                                                                       at http://www.blueshieldca.com. See the Claims Administra-
2. fraud, misrepresentations or omissions;                             tor Preferred Providers section for information on the advan-
                                                                       tages of choosing a Preferred Provider.
3. failure to comply with the Claims Administra-
   tor's applicable eligibility, participation or con-                 THE CLAIMS ADMINISTRATOR ONLINE
   tribution rules;
                                                                       The Claims Administrator’s Internet site is located at
4. termination of plan type by the Claims Admin-                       http://www.blueshieldca.com. Members with Internet access
   istrator;                                                           and a Web browser may view and download healthcare in-
                                                                       formation.
5. Employer moves out of the service area;
6. association membership ceases.                                      BENEFITS MANAGEMENT PROGRAM
                                                                       The Claims Administrator has established the Benefits Man-
All groups will renew subject to the above.
                                                                       agement Program to assist you, your Dependents or provider
SERVICES FOR EMERGENCY CARE                                            in identifying the most appropriate and cost-effective course
                                                                       of treatment for which certain Benefits will be provided un-
The Benefits of this Plan will be provided for covered Ser-            der this health Plan and for determining whether the services
vices received anywhere in the world for the emergency care            are Medically Necessary. However, you, your Dependents
of an illness or injury.                                               and provider make the final decision concerning treatment.
                                                                       The Benefits Management Program includes: prior authoriza-
Participants who reasonably believe that they have an emer-
                                                                       tion review for certain services, emergency admission notifi-
gency medical condition which requires an emergency re-
                                                                       cation, Hospital Inpatient review, discharge planning, and
sponse are encouraged to appropriately use the “911” emer-
                                                                       case management if determined to be applicable and appro-
gency response system where available.
                                                                       priate by the Claims Administrator.

SECOND MEDICAL OPINION POLICY                                          In some cases, the Benefits Management Program requires
                                                                       you to contact the Claims Administrator and/or follow the
If you have a question about your diagnosis, or believe that           Claims Administrator’s recommendations. Failure to contact
additional information concerning your condition would be              the Plan for authorization of services listed in the sections
helpful in determining the most appropriate plan of treat-             below or failure to follow the Plan’s recommendations may
ment, you may make an appointment with another Physician               result in reduced payment or non-payment if the Claims Ad-
for a second medical opinion. Your attending Physician may             ministrator determines the service was not a covered Service.
also offer to refer you to another Physician for a second opin-        Please read the following sections thoroughly so you under-
ion.                                                                   stand your responsibilities in reference to the Benefits Man-


                                                                  23
agement Program. Remember that all provisions of the                    1.   Admission into an approved Hospice Program as speci-
Benefits Management Program also apply to your Depend-                       fied under Hospice Program Benefits in the Covered
ents.                                                                        Services section.
The Claims Administrator requires prior authorization for               2.   Clinical Trial for Cancer Benefits.
selected Inpatient and Outpatient services, supplies and Du-
                                                                             Members who have been accepted into an approved
rable Medical Equipment; PKU related formulas and Special
                                                                             clinical trial for cancer as defined under the Covered
Food Products; admission into an approved Hospice Pro-
                                                                             Services section must obtain prior authorization from the
gram; and certain radiology procedures. Prior authorization
                                                                             Claims Administrator in order for the routine patient
is required for all Inpatient Hospital and Skilled Nursing Fa-
                                                                             care delivered in a clinical trial to be covered.
cility services (except for Emergency Services*).
                                                                        Failure to obtain prior authorization or to follow the recom-
*See the paragraph entitled Emergency Admission Notifica-
                                                                        mendations of the Claims Administrator for Hospice Pro-
tion later in this section for notification requirements.
                                                                        gram Benefits and Clinical Trial for Cancer Benefits above
By obtaining prior authorization for certain services prior to          will result in non-payment of services by the Claims Admin-
receiving services, you and your provider can verify: (1) if            istrator.
the Claims Administrator considers the proposed treatment
                                                                        3.   Select injectable drugs administered in the Physician
Medically Necessary, (2) if Plan Benefits will be provided
                                                                             office setting.*
for the proposed treatment, and (3) if the proposed setting is
the most appropriate as determined by the Claims Adminis-                    *Prior authorization is based on Medical Necessity, ap-
trator. You and your provider may be informed about Ser-                     propriateness of therapy, or when effective alternatives
vices that could be performed on an Outpatient basis in a                    are available.
Hospital or Outpatient Facility.
                                                                             Note: Your Preferred or Non-Preferred Physician must
                                                                             obtain prior authorization for select injectable drugs ad-
PRIOR AUTHORIZATION                                                          ministered in the Physician’s office. Failure to obtain
For Services and supplies listed in the section below, you or                prior authorization or to follow the recommendations of
your provider can determine before the service is provided                   the Claims Administrator for select injectable drugs may
whether a procedure or treatment program is a Covered Ser-                   result in non-payment by the Claims Administrator if the
vice and may also receive a recommendation for an alterna-                   service is determined not to be a covered Service; in that
tive Service. Failure to contact the Claims Administrator as                 event you may be financially responsible for services
described below or failure to follow the recommendations of                  rendered by a Non-Preferred Physician.
the Claims Administrator for Covered Services will result in            4.   Home Health Care Benefits from Non-Preferred Provid-
a reduced payment per procedure as described in the section                  ers.
entitled Reduced Payments for Failure to Use the Benefits
Management Program.                                                     5.   Home Infusion/Home Injectable Therapy Benefits from
                                                                             Non-Preferred Providers.
For Services other than those listed in the sections below,
you, your Dependents or provider should consult the Princi-             6.   Durable Medical Equipment Benefits, including but not
pal Benefits and Coverages (Covered Services) section of                     limited to motorized wheelchairs, insulin infusion
this booklet to determine whether a service is covered.                      pumps, and CPAP (Continuous Positive Air Pressure)
                                                                             machines.
You or your Physician must call the Customer Service tele-
phone number indicated on the back of the Member’s identi-              7.   Reconstructive Surgery.
fication card for prior authorization for the services listed in        8.   Arthroscopic surgery of the temporomandibular joint
this section except for the Outpatient radiological procedures               (TMJ) Services.
described in item 12. below. For prior authorization for Out-
patient radiological procedures, you or your Physician must             9.   Dialysis Services as specified under the Dialysis Center
call 1-888-642-2583.                                                         Benefits and Hospital Benefits (Facility Services) in the
                                                                             Covered Services section.
You or your Physician must call the Customer Service tele-
phone number indicated on the back of the Member’s identi-              10. Hemophilia home infusion products and Services.
fication card for prior authorization of Outpatient Partial
                                                                        Failure to obtain prior authorization or to follow the recom-
Hospitalization, Intensive Outpatient Care and Outpatient
                                                                        mendations of the Claims Administrator for:
electroconvulsive therapy (ECT) Services for the treatment
of Mental Health Conditions.                                                 injectable drugs administered in the Physician office set-
                                                                                 ting,
The Claims Administrator requires prior authorization for the
following services:                                                          Home Health Care Benefits from Non-Preferred Provid-
                                                                               ers,




                                                                   24
    Home Infusion/Home Injectable Therapy Benefits from                    Outpatient psychiatric Partial Hospitalization and Outpa-
      Non-Preferred Providers,                                             tient ECT Services, and
    Durable Medical Equipment Benefits,                                    dental and orthodontic Services that are an integral part
                                                                           of Reconstructive Surgery for cleft palate procedures
    cosmetic surgery services,
                                                                      as described above will result in a reduced payment as de-
    arthroscopic surgery of the TMJ services,
                                                                      scribed in the Additional and Reduced Payments for Failure
    dialysis Services, and                                            to Use the Benefits Management Program section or may
                                                                      result in non-payment if the Claims Administrator determines
    hemophilia home infusion products and supplies
                                                                      that the service is not a covered Service.
as described above may result in non-payment of services by           Other specific services and procedures may require prior
the Claims Administrator.                                             authorization as determined by the Claims Administrator. A
11. PKU Related Formulas and Special Food Products                    list of services and procedures requiring prior authorization
    Benefits.                                                         can be obtained by your provider by going to
                                                                      http://www.blueshieldca.com or by calling the Customer
12. The following radiological procedures when performed              Service telephone number indicated on the back of the Mem-
    in an Outpatient setting on a non-emergency basis:                ber’s identification card.
    CT (Computerized Tomography) scans, MRIs (Mag-
    netic Resonance Imaging), MRAs (Magnetic Resonance                HOSPITAL AND SKILLED NURSING FACILITY
    Angiography), PET (Positron Emission Tomography)                  ADMISSIONS
    scans, and any cardiac diagnostic procedure utilizing
    Nuclear Medicine.                                                 Prior authorization must be obtained from the Claims Ad-
                                                                      ministrator for all Hospital and Skilled Nursing Facility ad-
    Prior authorization is not required for these radiological        missions (except for admissions required for Emergency Ser-
    services when obtained outside of California. See the             vices). Included are Hospitalizations for continuing Inpatient
    “Out-Of-Area Program: The BlueCard Program” sec-                  Rehabilitation and skilled nursing care, transplants, bariatric
    tion of this booklet for an explanation of how payment is         surgery, and Inpatient Mental Health Services described later
    made for out of state services.                                   in this section.
13. Special Transplant Benefits as specified under Trans-
                                                                      Prior Authorization for Other than Mental Health
    plant Benefits - Special in the Covered Services section.
                                                                      Admissions
14. All bariatric surgery.
                                                                      Whenever a Hospital or Skilled Nursing Facility admission is
15. Outpatient Speech Therapy Services as specified under             recommended by your Physician, you or your Physician must
    Speech Therapy Benefits in the Covered Services sec-              contact the Claims Administrator at the Customer Service
    tion.                                                             telephone number indicated on the back of the Member’s
                                                                      identification card at least 5 business days prior to the admis-
16. Hospital and Skilled Nursing Facility admissions (see             sion. However, in case of an admission for Emergency Ser-
    the subsequent Hospital and Skilled Nursing Facility              vices, the Claims Administrator should receive emergency
    Admissions section for more information).                         admission notification within 24 hours or by the end of the
17. Outpatient Partial Hospitalization, Intensive Outpatient          first business day following the admission, or as soon as it is
    Care and Outpatient ECT Services for the treatment of             reasonably possible to do so. The Claims Administrator will
    Mental Health Conditions.                                         discuss the Benefits available, review the medical informa-
                                                                      tion provided and may recommend that to obtain the full
18. Medically Necessary dental and orthodontic Services               Benefits of this health Plan that the Services be performed on
    that are an integral part of Reconstructive Surgery for           an Outpatient basis.
    cleft palate procedures.
                                                                      Examples of procedures that may be recommended to be
Failure to obtain prior authorization or to follow the recom-         performed on an Outpatient basis if medical conditions do
mendations of the Claims Administrator for:                           not indicate Inpatient care include:
    PKU Related Formulas and Special Food Products                    1.   Biopsy of lymph node, deep axillary;
    Benefits,
                                                                      2.   Hernia repair, inguinal;
    Outpatient radiological procedures as specified above,
                                                                      3.   Esophagogastroduodenoscopy with biopsy;
    Special Transplant Benefits,
                                                                      4.   Excision of ganglion;
    all bariatric surgery,
                                                                      5.   Repair of tendon;
    Outpatient Speech Therapy Services,
                                                                      6.   Heart catheterization;
    Hospital and Skilled Nursing Facility admissions,


                                                                 25
7.   Diagnostic bronchoscopy;                                           tine decision making process might seriously jeopardize the
                                                                        life or health of a Member or when the Member is experienc-
8.   Creation of arterial venous shunts (for hemodialysis).
                                                                        ing severe pain, the Claims Administrator will respond as
Failure to contact the Claims Administrator as described or             soon as possible to accommodate the Member’s condition
failure to follow the recommendations of the Claims Admin-              not to exceed 72 hours from receipt of the request.
istrator will result in an additional payment per admission as
described in the Additional and Reduced Payments for Fail-              EMERGENCY ADMISSION NOTIFICATION
ure to Use the Benefits Management Program section or may
result in reduction or non-payment by the Claims Adminis-               If you are admitted for Emergency Services, the Claims Ad-
trator if it is determined that the admission is not a covered          ministrator should receive Emergency Admission Notifica-
Service.*                                                               tion within 24 hours or by the end of the first business day
                                                                        following the admission, or as soon as it is reasonably possi-
*Note: For admissions for special transplant Benefits, failure          ble to do so, or you may be responsible for the reduction in
to receive prior authorization in writing and/or failure to have        coverage as described under the Reduced Payments for Fail-
the procedure performed at the Claims Administrator desig-              ure to Use the Benefits Management Program section.
nated facility will result in non-payment of services by the
Claims Administrator. See Transplant Benefits under the                 HOSPITAL INPATIENT REVIEW
Covered Services section for details.
                                                                        The Claims Administrator monitors Inpatient stays. The stay
Prior Authorization for Inpatient Mental Health                         may be extended or reduced as warranted by your condition,
Services, Outpatient Partial Hospitalization,                           except in situations of maternity admissions for which the
Intensive Outpatient Care and Outpatient ECT                            length of stay is 48 hours or less for a normal, vaginal deliv-
Services                                                                ery or 96 hours or less for a Cesarean section unless the at-
All Inpatient Mental Health Services, Outpatient Partial Hos-           tending Physician, in consultation with the mother, deter-
pitalization, Intensive Outpatient Care and Outpatient ECT              mines a shorter Hospital length of stay is adequate. Also, for
Services, except for Emergency Services, must be prior au-              mastectomies or mastectomies with lymph node dissections,
thorized by the Claims Administrator.                                   the length of Hospital stays will be determined solely by your
                                                                        Physician in consultation with you. When a determination is
For an admission for Emergency Mental Health Services, the              made that the Member no longer requires the level of care
Claims Administrator should receive emergency admission                 available only in an Acute Care Hospital, written notification
notification within 24 hours or by the end of the first business        is given to you and your Doctor of Medicine. You will be
day following the admission, or as soon as it is reasonably             responsible for any Hospital charges Incurred beyond 24
possible to do so, or the Participant may be responsible for            hours of receipt of notification.
the additional payment as described below.
For prior authorization of Inpatient Mental Health Services,            DISCHARGE PLANNING
Intensive Outpatient Care, Outpatient Partial Hospitalization           If further care at home or in another facility is appropriate
and Outpatient ECT Services, call the Customer Service tele-            following discharge from the Hospital, the Claims Adminis-
phone number indicated on the back of the Member’s identi-              trator will work with the Physician and Hospital discharge
fication card.                                                          planners to determine whether benefits are available under
Failure to contact the Claims Administrator as described                this Plan to cover such care.
above or failure to follow the recommendations of the Claims
Administrator will result in an additional payment per admis-           CASE MANAGEMENT
sion as described in the Additional and Reduced Payments
                                                                        The Benefits Management Program may also include case
for Failure to Use the Benefits Management Program section
                                                                        management, which provides assistance in making the most
or may result in reduction or non-payment by the Claims
                                                                        efficient use of the Plan Benefits. Individual case manage-
Administrator if it is determined that the admission is not a
                                                                        ment may also arrange for alternative care benefits in place
covered Service. For Outpatient Partial Hospitalization, In-
                                                                        of prolonged or repeated hospitalizations, when it is deter-
tensive Outpatient Care and Outpatient ECT Services, failure
                                                                        mined to be appropriate through a Claims Administrator re-
to contact the Claims Administrator as described above or
                                                                        view. Such alternative care benefits will be available only by
failure to follow the recommendations of the Claims Admin-
                                                                        mutual consent of all parties and, if approved, will not exceed
istrator will result in non-payment of services by the Claims
                                                                        the Benefit to which you would otherwise have been entitled
Administrator.
                                                                        under this Plan. The Claims Administrator is not obligated to
Note: The Claims Administrator will render a decision on all            provide the same or similar alternative care benefits to any
requests for prior authorization within 5 business days from            other person in any other instance. The approval of alterna-
receipt of the request. The treating provider will be notified          tive benefits will be for a specific period of time and will not
of the decision within 24 hours followed by written notice to           be construed as a waiver of the Claims Administrator’s right
the provider and Participant within 2 business days of the              to thereafter administer this health Plan in strict accordance
decision. For urgent services in situations in which the rou-           with its express terms.


                                                                   26
REDUCED PAYMENTS FOR FAILURE TO                                         DEDUCTIBLES
USE THE BENEFITS MANAGEMENT
                                                                        1. INDIVIDUAL COVERAGE DEDUCTIBLE
PROGRAM
                                                                           (APPLICABLE TO 1 MEMBER COVERAGE)
For non-emergency Services, payments may be reduced, as
described below, when a Participant or Dependent fails to                   The Calendar Year Deductible amount is shown in the
follow the procedures described under the Prior Authoriza-                  Summary of Benefits. This Deductible must be made up
tion and Hospital and Skilled Nursing Facility Admissions                   of charges covered by the Plan and must be satisfied
sections of the Benefits Management Program.                                once during each Calendar Year. After the Calendar
                                                                            Year Deductible is satisfied for those Services to which
1.   Failure to contact the Claims Administrator as described               it applies, Benefits will be provided for covered Ser-
     under the Prior Authorization of the Benefits Manage-                  vices.
     ment Program or failure to follow the recommendations
     of the Claims Administrator will result in an additional               Charges in excess of the Allowable Amount do not ap-
     payment per Hospital or Skilled Nursing Facility admis-                ply toward the Deductible.
     sion as described below or may result in reduction or                  Note: If you are enrolled in an Individual Deductible
     non-payment by the Claims Administrator if it is deter-                Plan, and have a newborn or a child placed for adoption,
     mined that the admission is not a covered Service.                     the child is covered for the first 31 days even if applica-
                                                                            tion is not made to add the child as a Dependent on the
     •   *$250 per Hospital or Skilled Nursing Facility ad-
                                                                            Plan. While the child’s coverage is provided, you and
         mission.
                                                                            this Dependent will be enrolled in the Family Coverage
     •   *$250 per Hospital admission for the diagnosis or                  Deductible Plan. The Family Deductible amount as de-
         treatment of Substance Abuse Conditions if sub-                    scribed in the Family Coverage Deductible section be-
         stance abuse coverage is selected as an optional                   low will apply to you and this Dependent.
         Benefit by your Employer. Note: Inpatient Services
         which are Medically Necessary to treat the acute               2. FAMILY COVERAGE DEDUCTIBLE
         medical complications of detoxification are covered               (APPLICABLE TO 2 OR MORE MEMBER
         as part of the medical Benefits and are not consid-
                                                                           COVERAGE)
         ered to be treatment of the Substance Abuse Condi-
         tion itself.                                                       The Calendar Year per Family Deductible amounts are
                                                                            shown in the Summary of Benefits. This Deductible
     Only one $250 additional payment will apply to each
                                                                            must be made up of charges covered by the Plan, and
     Hospital admission for failure to follow the Benefits
                                                                            must be satisfied once during each Calendar Year.
     Management Program notification requirements or rec-
                                                                            Charges Incurred by one or all of the Family members in
     ommendations.
                                                                            combination will be used to calculate the Calendar Year
2.   Failure to obtain prior authorization or to follow the rec-            Family Coverage Deductible. After the Calendar Year
     ommendations of the Claims Administrator for Outpa-                    Deductible is satisfied for those Services to which it ap-
     tient Partial Hospitalization, Intensive Outpatient Care               plies, Benefits will be provided for covered Services to
     and Outpatient ECT Services, will result in non-payment                any and all Family members.
     of services by the Claims Administrator.
                                                                            Charges in excess of the Allowable Amount do not ap-
3.   Failure to obtain prior authorization or to follow the rec-            ply toward the Deductible.
     ommendations of the Claims Administrator for covered,
                                                                            These Calendar Year Deductibles will count towards the
     Medically Necessary enteral formulas and Special Food
                                                                            Calendar Year maximum out-of-pocket responsibility.
     Products for the treatment of phenylketonuria (PKU)
     will result in a 50% reduction in the amount payable by
     the Claims Administrator after the calculation of the De-          SERVICES NOT SUBJECT TO THE DEDUCTIBLE
     ductible and any applicable Copayments required by this            The Calendar Year Deductible applies to all covered Services
     Plan. You will be responsible for the applicable De-               Incurred during a Calendar Year except for certain Services
     ductibles and/or Copayments and the additional 50% of              as listed in the Summary of Benefits.
     the charges that are payable under this Plan.
4.   Failure to receive prior authorization for the radiological        LAST QUARTER CARRY OVER
     procedures listed in the Benefits Management Program               If charges for covered Services received during the last 3
     section under Prior Authorization or to follow the rec-            months of the Calendar Year are applied to the deductible,
     ommendations of the Claims Administrator will result in            the deductible for the next Calendar Year will be reduced by
     non-payment for procedures which are determined not to             that amount.
     be covered Services.



                                                                   27
PRIOR CARRIER DEDUCTIBLE CREDIT                                               charges, except that services of physicians and hospitals
                                                                              are paid based on the Allowable Amount. Participants
If you satisfied all or part of a medical Deductible under a                  are responsible for the remaining Copayment.
health plan sponsored by your Employer or under an Individ-
ual and Family Health Plan (IFP) issued by the Claims Ad-                If you do not see a Participating Provider through the Blue-
ministrator during the same Calendar Year this Plan becomes              Card Program, you will have to pay for the entire bill for
effective, that amount will be applied to the medical De-                your medical care and submit a claim to the local Blue Cross
ductible required under this Plan.                                       and/or Blue Shield plan, or to the Claims Administrator for
                                                                         payment. The Claims Administrator will notify you of its
Note: This Prior Carrier Deductible Credit provision applies             determination within 30 days after receipt of the claim. The
only to new Employees who are enrolling on the original                  Claims Administrator will pay you at the Non-Preferred Pro-
effective date of this Plan, if this health Plan allows credit of        vider benefit level. Remember, your copayment is higher
the medical Deductible from the Employer's previous health               when you see a Non-Preferred Provider. You will be respon-
plan.                                                                    sible for paying the entire difference between the amount
                                                                         paid by the Claims Administrator and the amount billed.
MAXIMUM AGGREGATE PAYMENT                                                Charges for Services which are not covered, and charges by
AMOUNT                                                                   Non-Preferred Providers in excess of the amount covered by
                                                                         the plan, are the Participant's responsibility and are not in-
There is no maximum limit on the aggregate payments by the               cluded in out-of-pocket calculations.
Plan for covered Services provided under the Plan.
                                                                         To receive the maximum benefits of your plan, please follow
                                                                         the procedure below.
PAYMENT
                                                                         When you require covered Services while traveling outside
The Participant Copayment amounts, applicable Deductibles,               of California:
and Copayment maximum amounts for covered Services are
shown in the Summary of Benefits. The Summary of Bene-                   1.   call BlueCard Access® at 1-800-810-BLUE (2583) to
fits also contains information on benefit and Copayment                       locate Physicians and Hospitals that participate with the
maximums and restrictions.                                                    local Blue Cross and/or Blue Shield plan, or go on-line
                                                                              at www.bcbs.com and select the “Find a Doctor or Hos-
Complete benefit descriptions may be found in the Principal                   pital” tab; and,
Benefits and Coverages (Covered Services) section. Plan
exclusions and limitations may be found in the Principal                 2.   visit the Participating Physician or Hospital and present
Limitations, Exceptions, Exclusions and Reductions section.                   your membership card.
Out-of-Area Program: The BlueCard® Program                               The Participating Physician or Hospital will verify your eli-
                                                                         gibility and coverage information by calling BlueCard Eligi-
Benefits will be provided, according to paragraphs (1.), (2.),           bility at 1-800-676-BLUE. Once verified and after Services
and (3.) below, for covered Services received outside of Cali-           are provided, a claim is submitted electronically and the Par-
fornia within the United States. The Claims Administrator                ticipating Physician or Hospital is paid directly. You may be
calculates the Participant's copayment as a percentage of the            asked to pay for your applicable copayment and plan De-
Allowable Amount, as defined in this booklet. When cov-                  ductible at the time you receive the service.
ered Services are received in another state, the Participant's
copayment will be based on the local Blue Cross and/or Blue              You will receive an Explanation of Benefits which will show
Shield plan's arrangement with its providers.                            your payment responsibility. You are responsible for the
                                                                         Copayment and plan Deductible amounts shown in the Ex-
1.   Covered Services received from a provider who has con-              planation of Benefits.
     tracted with the local Blue Cross and/or Blue Shield plan
     are paid at the Preferred level. Participants are responsi-         Prior authorization is required for all Inpatient Hospital Ser-
     ble for the remaining Copayment.                                    vices and notification is required for Inpatient Emergency
                                                                         Services. Prior authorization is required for selected Inpatient
2.   Non-emergency covered Services received from provid-                and Outpatient Services, supplies and Durable Medical
     ers who have not contracted with the local Blue Cross               Equipment. To receive prior authorization from the Claims
     and/or Blue Shield plan are paid at the Non-Preferred               Administrator, the out-of-area provider should call the Cus-
     level of the local Blue Cross and/or Blue Shield plan’s             tomer Service telephone number indicated on the back of the
     Allowable Amount. Participants are responsible for the              Member’s identification card.
     remaining Copayment as well as any charges in excess
     of the local Blue Cross and/or Blue Shield plan’s Allow-            If you need Emergency Services, you should seek immediate
     able Amount.                                                        care from the nearest medical facility. The Benefits of this
                                                                         plan will be provided for covered Services received any-
3.   Emergency Services received from providers who have                 where in the world for emergency care of an illness or injury.
     not contracted with the local Blue Cross and/or Blue
     Shield plan are paid at the Preferred level of billed


                                                                    28
Care for Covered Urgent Care and Emergency Services                      statutes mandate Participant liability calculation methods that
Outside the United States                                                differ from the usual BlueCard Program method noted above
                                                                         or require a surcharge, the Claims Administrator would then
Benefits will also be provided for covered Services received
                                                                         calculate your liability for any covered health care services in
outside of the United States through the BlueCard World-
                                                                         accordance with the applicable state statute in effect at the
wide® Network. If you need urgent care while out of the
                                                                         time you received your care.
country, call either the toll-free BlueCard Access number at
1-800-810-2583 or call collect at 1-804-673-1177, 24 hours a             For any other providers, the amount you pay, if not subject to
day, seven days a week. In an emergency, go directly to the              a flat dollar copayment, is calculated on the provider’s Al-
nearest hospital. If your coverage requires precertification or          lowable Amount for your covered services.
prior authorization, you should call the Claims Administrator
at the Customer Service telephone number indicated on the                CALENDAR YEAR MAXIMUM OUT-OF-
back of the Member’s identification card. For inpatient hos-
pital care at participating hospitals, show your I.D. card to the        POCKET RESPONSIBILITY
hospital staff upon arrival. You are responsible for the usual
out-of-pocket expenses (non-covered charges, Deductibles,                1. INDIVIDUAL COVERAGE
and Copayments).                                                            (APPLICABLE TO 1 MEMBER COVERAGE)
When you receive services from a physician, you will have to             The per Member maximum out-of-pocket responsibility re-
pay the doctor and then submit a claim. Also for inpatient               quired each Calendar Year for covered Services is shown in
hospitalization, if you do not use the BlueCard Worldwide                the Summary of Benefits.
Network, you will have to pay the entire bill for your medical
care and submit a claim form (with a copy of the bill) to the            Once the maximum out-of-pocket responsibility has been
Claims Administrator.                                                    met, the Plan will pay 100% of the Allowable Amount for
                                                                         covered Services for the remainder of that Calendar Year.
Before traveling abroad, call your local Customer Service
office for the most current listing of participating Hospitals           2. FAMILY COVERAGE
worldwide or you can go on-line at www.bcbs.com and se-
lect “Find a Doctor or Hospital”.                                           (APPLICABLE TO 2 OR MORE MEMBER
                                                                            COVERAGE)
Calculation of your Deductibles, Copayments and maximum
out-of-pocket responsibilities under the BlueCard Program:               The per Family maximum out-of-pocket responsibility re-
                                                                         quired each Calendar Year for covered Services* is shown in
When you obtain health care services through the BlueCard                the Summary of Benefits. The Family maximum out-of-
Program outside of California, the amount you pay for cov-               pocket responsibility will be satisfied by the Member and all
ered services is calculated on the lower of:                             of his covered Dependents collectively.
1.   The Allowable Amount for your covered services, or                  Once the maximum out-of-pocket responsibility has been
2.   The negotiated price that the local Blue Cross and/or               met*, the Plan will pay 100% of the Allowable Amount for
     Blue Shield plan passes on to us.                                   covered Services for the remainder of that Calendar Year.
Often, this “negotiated price” will consist of a simple dis-             *Note: Certain Services and amounts are not included in the
count which reflects the actual price paid by the local Blue             Calendar Year maximum out-of-pocket responsibility calcu-
Cross and/or Blue Shield plan. But sometimes it is an esti-              lations. These items are shown in the Summary of Benefits.
mated price that factors into the actual price expected settle-          Charges for Services which are not covered, charges above
ments, withholds, any other contingent payment arrange-                  the Allowable Amount, charges in excess of the amount cov-
ments and non-claims transactions with your health care pro-             ered by the Plan, and Reduced Payments Incurred under the
vider or with a specified group of providers. The negotiated             Benefits Management Program are the Subscriber's responsi-
price may also be billed charges reduced to reflect an average           bility and are not included in the Calendar Year maximum
expected savings with your health care provider or with a                out-of-pocket responsibility calculations.
specified group of providers. The price that reflects average
savings may result in greater variation (more or less) from              For the Outpatient Prescription Drugs Benefit, if the Sub-
the actual price paid than will the estimated price. The nego-           scriber requests a brand name drug when a generic drug
tiated price will also be adjusted in the future to correct for          equivalent is available, the difference in cost that the Sub-
over or underestimation of past prices. However, the amount              scriber must pay is not included in the Calendar Year maxi-
you pay is considered a final price.                                     mum out-of-pocket responsibility calculations. See the Out-
                                                                         patient Prescription Drugs Benefits section for details.
Statutes in a small number of states may require the local
Blue Cross and/or Blue Shield plan to use a basis for calcu-
lating Participant liability for covered Services that does not
reflect the entire savings realized, or expected to be realized,
on a particular claim or to add a surcharge. Should any state


                                                                    29
PRINCIPAL BENEFITS AND COVERAGES                                         Outpatient Services including general anesthesia and associ-
                                                                         ated facility charges in connection with dental procedures are
(COVERED SERVICES)                                                       covered when performed in an ambulatory surgery center
Benefits are provided for the following Medically Necessary              because of an underlying medical condition or clinical status
covered Services, subject to applicable Deductibles, Copay-              and the Member is under the age of seven or developmen-
ments and charges in excess of Benefit maximums, Preferred               tally disabled regardless of age or when the Member’s health
Provider provisions and Benefits Management Program pro-                 is compromised and for whom general anesthesia is Medi-
visions. Coverage for these Services is subject to all terms,            cally Necessary regardless of age. This benefit excludes den-
conditions, limitations and exclusions of the Contract, to any           tal procedures and services of a dentist or oral surgeon.
conditions or limitations set forth in the benefit descriptions          Note: Reconstructive Surgery is only covered when there is
below, and to the Principal Limitations, Exceptions, Exclu-              no other more appropriate covered surgical procedure, and
sions and Reductions listed in this booklet. If there are two            with regards to appearance, when Reconstructive Surgery
or more Medically Necessary services that may be provided                offers more than a minimal improvement in appearance. In
for the illness, injury or medical condition, the Claims Ad-             accordance with the Women’s Health & Cancer Rights Act,
ministrator will provide Benefits based on the most cost-                Reconstructive Surgery is covered on either breast to restore
effective service.                                                       and achieve symmetry incident to a mastectomy, including
The Copayments, if applicable, are shown in the Summary of               treatment of physical complications of a mastectomy and
Benefits.                                                                lymphedemas. For coverage of prosthetic devices incident to
                                                                         a mastectomy, see Reconstructive Surgery under Professional
All Copayments will be calculated as described in the Pay-               (Physician) Benefits. Benefits will be provided in accor-
ment section of this booklet.                                            dance with guidelines established by the Plan and developed
Note: Except as may be specifically indicated, for Services              in conjunction with plastic and reconstructive surgeons.
received from Non-Preferred and Non-Participating Provid-                No benefits will be provided for the following surgeries or
ers Participants will be responsible for all charges above the           procedures unless for Reconstructive Surgery:
Allowable Amount in addition to the indicated dollar or per-
centage Participant Copayment.                                               Surgery to excise, enlarge, reduce, or change the ap-
                                                                             pearance of any part of the body;
Except as specifically provided herein, Services are covered
only when rendered by an individual or entity that is licensed               Surgery to reform or reshape skin or bone;
or certified by the state to provide health care services and is             Surgery to excise or reduce skin or connective tissue
operating within the scope of that license or certification.                 that is loose, wrinkled, sagging, or excessive on any
                                                                             part of the body;
ACUPUNCTURE BENEFITS
                                                                             Hair transplantation; and
Benefits are provided for acupuncture evaluation and treat-
                                                                             Upper eyelid blepharoplasty without documented sig-
ment by a Doctor of Medicine (M.D.) or a certificated acu-
                                                                             nificant visual impairment or symptomatology.
puncturist up to a per visit dollar maximum shown on the
Summary of Benefits.                                                     This limitation shall not apply to breast reconstruction when
                                                                         performed subsequent to a mastectomy, including surgery on
Benefits are limited to a per Member per Calendar Year
                                                                         either breast to achieve or restore symmetry.
Benefit maximum as shown on the Summary of Benefits.

ALLERGY TESTING AND TREATMENT BENEFITS                                   BARIATRIC SURGERY BENEFITS
                                                                         Benefits are provided for Hospital and professional Services
Benefits are provided for allergy testing and treatment.
                                                                         in connection with Medically Necessary bariatric surgery to
                                                                         treat morbid or clinically severe obesity.
AMBULANCE BENEFITS
                                                                         All bariatric surgery Services must be prior authorized, in
Benefits are provided for (1) Medically Necessary ambulance              writing, from the Claims Administrator’s Medical Director.
Services (surface and air) when used to transport a Member               Prior authorization is required for all Members.
from place of illness or injury to the closest medical facility
where appropriate treatment can be received, or (2) Medi-
cally Necessary ambulance transportation from one medical
                                                                         CHIROPRACTIC BENEFITS
facility to another.                                                     Benefits are provided for any Medically Necessary Chiro-
                                                                         practic Services rendered by a chiropractor. The chiropractic
AMBULATORY SURGERY CENTER BENEFITS                                       benefit includes the initial and subsequent office visits, an
                                                                         initial examination, adjustments, conjunctive therapy, and lab
Ambulatory surgery Services means surgery which does not                 and X-ray Services.
require admission to a Hospital (or similar facility) as a regis-
tered bed patient.


                                                                    30
Benefits are limited to a combined per Member per Calendar               or
Year visit maximum with Outpatient Rehabilitation Services
                                                                         2. Involves a drug that is exempt under federal regulations
as shown in the Summary of Benefits.
                                                                            from a new drug application.
Covered lab and X-ray Services provided in conjunction with
this Benefit have an additional Copayment as shown under                 DIABETES CARE BENEFITS
the Outpatient X-ray, Pathology and Laboratory Benefits
section.                                                                 Diabetes Equipment
                                                                         Benefits are provided for the following devices and equip-
CLINICAL TRIAL FOR CANCER BENEFITS                                       ment, including replacement after the expected life of the
Benefits are provided for routine patient care for Members               item and when Medically Necessary, for the management
who have been accepted into an approved clinical trial for               and treatment of diabetes when Medically Necessary:
cancer when prior authorized by the Claims Administrator,                a.   blood glucose monitors, including those designed to
and:                                                                          assist the visually impaired;
1.   the clinical trial has a therapeutic intent and the Mem-            b.   Insulin pumps and all related necessary supplies;
     ber’s treating Physician determines that participation in
     the clinical trial has a meaningful potential to benefit the        c.   podiatric devices to prevent or treat diabetes-related
     Member with a therapeutic intent; and                                    complications, including extra-depth orthopedic shoes;

2.   the Member’s treating Physician recommends participa-               d.   visual aids, excluding eyewear and/or video-assisted
     tion in the clinical trial; and                                          devices, designed to assist the visually impaired with
                                                                              proper dosing of Insulin.
3.   the Hospital and/or Physician conducting the clinical
     trial is a Participating Provider, unless the protocol for          For coverage of diabetic testing supplies including blood and
     the trial is not available through a Participating Provider.        urine testing strips and test tablets, lancets and lancet punc-
                                                                         ture devices and pen delivery systems for the administration
Services for routine patient care will be paid on the same               of insulin, refer to the Outpatient Prescription Drugs Bene-
basis and at the same Benefit levels as other covered Services           fits.
shown in the Summary of Benefits.
                                                                         Diabetes Outpatient Self-Management Training
Routine patient care consists of those Services that would
otherwise be covered by the Plan if those Services were not              Benefits are provided for diabetes Outpatient self-
provided in connection with an approved clinical trial, but              management training, education and medical nutrition ther-
does not include:                                                        apy that is Medically Necessary to enable a Participant to
                                                                         properly use the devices, equipment and supplies, and any
1. Drugs or devices that have not been approved by the fed-              additional Outpatient self-management training, education
   eral Food and Drug Administration (FDA);                              and medical nutrition therapy when directed or prescribed by
2. Services other than health care services, such as travel,             the Member’s Physician. These Benefits shall include, but
   housing, companion expenses and other non-clinical ex-                not be limited to, instruction that will enable diabetic patients
   penses;                                                               and their families to gain an understanding of the diabetic
                                                                         disease process, and the daily management of diabetic ther-
3. Any item or service that is provided solely to satisfy data           apy, in order to thereby avoid frequent hospitalizations and
   collection and analysis needs and that is not used in the             complications. Services will be covered when provided by
   clinical management of the patient;                                   Physicians, registered dieticians or registered nurses who are
4. Services that, except for the fact that they are being pro-           certified diabetes educators.
   vided in a clinical trial, are specifically excluded under
   the Plan;                                                             DIALYSIS CENTER BENEFITS
5. Services customarily provided by the research sponsor                 Benefits are provided for Medically Necessary dialysis Ser-
   free of charge for any enrollee in the trial.                         vices, including renal dialysis, hemodialysis, peritoneal di-
                                                                         alysis and other related procedures.
An approved clinical trial is limited to a trial that is:
                                                                         Included in this Benefit are Medically Necessary dialysis
1. Approved by one of the following:
                                                                         related laboratory tests, equipment, medications, supplies and
     a.   one of the National Institutes of Health;                      dialysis self-management training for home dialysis.
     b.   the federal Food and Drug Administration, in the               Note: Prior authorization by the Claims Administrator is
          form of an investigational new drug application;               required for all dialysis services. See the Benefits Manage-
                                                                         ment Program section for details.
     c.   the United States Department of Defense;
     d.   the United States Veterans Administration;


                                                                    31
DURABLE MEDICAL EQUIPMENT BENEFITS                                     Services. The Participant Copayment for non-emergency
                                                                       Inpatient Hospital Services from a Non-Preferred Hospital is
Medically Necessary Durable Medical Equipment for Activi-              shown in the Summary of Benefits.
ties of Daily Living, supplies needed to operate Durable
Medical Equipment, oxygen and its administration, and                  For Emergency Room Services directly resulting in an ad-
ostomy and medical supplies to support and maintain gastro-            mission to a different Hospital, the Participant is responsible
intestinal, bladder or respiratory function are covered. Other         for the emergency room Participant Copayment plus the ap-
covered items include peak flow monitors for self-                     propriate admitting Hospital Services Participant Copayment
management of asthma, the glucose monitor for self-                    as shown in the Summary of Benefits.
management of diabetes, apnea monitors for management of
                                                                       FAMILY PLANNING BENEFITS
newborn apnea, and the home prothrombin monitor for spe-
cific conditions as determined by the Claims Administrator.            Benefits are provided for the following Family Planning Ser-
Benefits are provided at the most cost-effective level of care         vices without illness or injury being present.
that is consistent with professionally recognized standards of
                                                                       Note: No benefits are provided for Family Planning Services
practice. If there are two or more professionally recognized
                                                                       diagnosis and treatment of cause Infertility and IUDs includ-
appliances equally appropriate for a condition, Benefits will
                                                                       ing insertion and removal of IUD from Non-Preferred Pro-
be based on the most cost-effective appliance.
                                                                       viders. No benefits are provided for IUDs when used for
Medically Necessary Durable Medical Equipment for Activi-              non-contraceptive reasons except the removal to treat Medi-
ties of Daily Living, including repairs, is covered as de-             cally Necessary Services related to complications.
scribed in this section, except as noted below:
                                                                       1.   Family planning counseling and consultation Services,
1.   No benefits are provided for rental charges in excess of               including Physician office visits for diaphragm fittings;
     the purchase cost;
                                                                       2.   Infertility Services, except as excluded in the Principal
2.   Replacement of Durable Medical Equipment is covered                    Limitations, Exceptions, Exclusions and Reductions sec-
     only when it no longer meets the clinical needs of the                 tion, including professional, Hospital, ambulatory sur-
     patient or has exceeded the expected lifetime of the                   gery center, and ancillary Services to diagnose and treat
     item*.                                                                 the cause of Infertility. Any services related to the har-
                                                                            vesting or stimulation of the human ovum, in-vitro fer-
     *This does not apply to the Medically Necessary re-
                                                                            tilization, artificial insemination, Gamete Intrafallopian
     placement of nebulizers, face masks and tubing, and
                                                                            Transfer (G.I.F.T.) procedure, or any other form of as-
     peak flow monitors for the management and treatment of
                                                                            sisted fertilization (including related medications, labo-
     asthma. (Note: See the Outpatient Prescription Drugs
                                                                            ratory and radiology service) are not covered;
     Benefits section for benefits for asthma inhalers and in-
     haler spacers.)                                                   3.   Intrauterine devices (IUDs), including insertion and/or
                                                                            removal;
No benefits are provided for environmental control equip-
ment, generators, self-help/educational devices, air condi-            4.   Injectable contraceptives when administered by a Physi-
tioners, humidifiers, dehumidifiers, air purifiers, exercise                cian;
equipment, or any other equipment not primarily medical in
                                                                       5.   Voluntary sterilization (tubal ligation and vasectomy)
nature. No benefits are provided for backup or alternate
                                                                            and elective abortions. No benefits are provided for con-
items.
                                                                            traceptives, except as may be provided under the Outpa-
Note: See the Diabetes Care Benefits section for devices,                   tient Prescription Drugs Benefits.
equipment, and supplies for the management and treatment
of diabetes.                                                           HOME HEALTH CARE BENEFITS
For Members in a Hospice Program through a Participating               Benefits are provided for home health care Services when the
Hospice Agency, medical equipment and supplies that are                Services are Medically Necessary, ordered by the attending
reasonable and necessary for the palliation and management             Physician, and included in a written treatment plan.
of Terminal Illness and related conditions are provided by the
Hospice Agency.                                                        Services by a Non-Participating Home Health Care Agency,
                                                                       shift care, private duty nursing and stand-alone health aide
                                                                       services must be prior authorized by the Claims Administra-
EMERGENCY ROOM SERVICES FOR TREATMENT                                  tor.
OF ILLNESS OR INJURY                                                   Covered Services are subject to any applicable Deductibles
Benefits are provided for Medically Necessary Services pro-            and Copayments. Visits by home health care agency provid-
vided in the Emergency Room of a Hospital.                             ers will be payable up to a combined per Member per Calen-
                                                                       dar Year visit maximum as shown in the Summary of Bene-
Note: Emergency Room Services resulting in an admission                fits.
to a Non-Preferred Hospital which the Plan determines are
not emergencies, will be paid as part of the Inpatient Hospital

                                                                  32
Intermittent and part-time visits by a home health agency to          Outpatient Prescription Drugs Benefits, and Services related
provide Skilled Nursing and other skilled Services are cov-           to hemophilia which are described below.
ered up to 4 visits per day, 2 hours per visit not to exceed 8
                                                                      Skilled Nursing Services are defined as a level of care that
hours per day by any of the following professional providers:
                                                                      includes services that can only be performed safely and cor-
1.   Registered nurse;                                                rectly by a licensed nurse (either a registered nurse or a li-
                                                                      censed vocational nurse).
2.   Licensed vocational nurse;
                                                                      Note: Benefits are also provided for infusion therapy pro-
3.   Physical therapist, occupational therapist, or speech
                                                                      vided in infusion suites associated with a Participating Home
     therapist;
                                                                      Infusion Agency.
4.   Certified home health aide in conjunction with the Ser-
                                                                      Note: Services rendered by Non-Participating Home Health
     vices of 1., 2., or 3. above;
                                                                      Care and Home Infusion agencies must be prior authorized
5.   Medical social worker.                                           by the Claims Administrator.
For the purpose of this Benefit, visits from home health aides
of 4 hours or less shall be considered as one visit.                  HEMOPHILIA HOME INFUSION PRODUCTS AND
                                                                      SERVICES
In conjunction with professional Services rendered by a
home health agency, medical supplies used during a covered            Benefits are provided for home infusion products for the
visit by the home health agency necessary for the home                treatment of hemophilia and other bleeding disorders. All
health care treatment plan and related laboratory Services are        Services must be prior authorized by the Claims Administra-
covered to the extent the Benefits would have been provided           tor (see the Benefits Management Program section for spe-
had the Member remained in the Hospital or Skilled Nursing            cific prior authorization requirements), and must be provided
Facility.                                                             by a Preferred Hemophilia Infusion Provider. (Note: Most
                                                                      Participating Home Health Care and Home Infusion Agen-
This Benefit does not include medications, drugs or in-               cies are not Preferred Hemophilia Infusion Providers.) To
jectables covered under the Home Infusion/Home Injectable             find a Preferred Hemophilia Infusion Provider, consult the
Therapy Benefits or under the Outpatient Prescription Drugs           Preferred Provider Directory. You may also verify this in-
Benefits.                                                             formation by calling Customer Service at the telephone num-
Skilled Nursing Services are defined as a level of care that          ber shown on the last page of this booklet.
includes services that can only be performed safely and cor-          Hemophilia Infusion Providers offer 24-hour service and
rectly by a licensed nurse (either a registered nurse or a li-        provide prompt home delivery of hemophilia infusion prod-
censed vocational nurse).                                             ucts.
(Note: See the Hospice Program Benefits section for infor-            Following evaluation by your Physician, a prescription for a
mation about when a Member is admitted into a Hospice                 blood factor product must be submitted to and approved by
Program and a specialized description of Skilled Nursing              the Claims Administrator. Once prior authorized by the
Services for hospice care.)                                           Claims Administrator, the blood factor product is covered on
Note: For information concerning diabetes self-management             a regularly scheduled basis (routine prophylaxis) or when a
training, see the Diabetes Care Benefits section.                     non-emergency injury or bleeding episode occurs. (Emer-
                                                                      gencies will be covered as described in the Emergency Room
HOME INFUSION/HOME INJECTABLE THERAPY                                 Benefits section.)
BENEFITS                                                              Included in this Benefit is the blood factor product for in-
                                                                      home infusion use by the Member, necessary supplies such
Benefits are provided for home infusion and intravenous (IV)
                                                                      as ports and syringes, and necessary nursing visits. Services
injectable therapy, except for Services related to hemophilia
                                                                      for the treatment of hemophilia outside the home, except for
which are described below. Services include home infusion
                                                                      Services in infusion suites managed by a Preferred Hemo-
agency skilled nursing visits, parenteral nutrition Services,
                                                                      philia Infusion Provider, and Medically Necessary Services
enteral nutrition Services and associated supplements, medi-
                                                                      to treat complications of hemophilia replacement therapy are
cal supplies used during a covered visit, pharmaceuticals
                                                                      not covered under this Benefit but may be covered under
administered intravenously, related laboratory Services and
                                                                      other medical benefits described elsewhere in this Principal
for Medically Necessary FDA approved injectable medica-
                                                                      Benefits and Coverages (Covered Services) section.
tions when prescribed by a Doctor of Medicine and provided
by a home infusion agency. Services from Non-Participating            This Benefit does not include:
Home Infusion Agencies, shift care and private duty nursing           1.   Physical therapy, gene therapy or medications including
must be prior authorized by the Claims Administrator.                      antifibrinolytic and hormone medications*;
This Benefit does not include medications, drugs, Insulin,            2.   Services from a hemophilia treatment center or any Non-
insulin syringes, certain Specialty Drugs covered under the                Preferred Hemophilia Infusion Provider; or,
                                                                      3.   Self-infusion training programs, other than nursing visits

                                                                 33
     to assist in administration of the product.                     8.   Short-term Inpatient care arrangements.
     *Services may be covered under the Rehabilitation               9.   Pharmaceuticals, medical equipment, and supplies that
     Benefits (Physical, Occupational and Respiratory Ther-               are reasonable and necessary for the palliation and
     apy), Outpatient Prescription Drug Benefits, or as de-               management of Terminal Illness and related condi-
     scribed elsewhere in this Principal Benefits and Cover-              tions.
     ages (Covered Services) section.
                                                                     10. Physical therapy, occupational therapy, and speech-
                                                                         language pathology Services for purposes of symptom
HOSPICE PROGRAM BENEFITS                                                 control, or to enable the enrollee to maintain activities
Benefits are provided for the following Services through a               of daily living and basic functional skills.
Participating Hospice Agency when an eligible Member re-             11. Nursing care Services are covered on a continuous
quests admission to and is formally admitted to an approved              basis for as much as 24 hours a day during Periods of
Hospice Program. The Member must have a Terminal Ill-                    Crisis as necessary to maintain a Member at home.
ness as determined by their Physician‘s certification and the            Hospitalization is covered when the Interdisciplinary
admission must receive prior approval from the Claims Ad-                Team makes the determination that skilled nursing
ministrator. (Note: Members with a Terminal Illness who                  care is required at a level that can’t be provided in the
have not elected to enroll in a Hospice Program can receive a            home. Either Homemaker Services or Home Health
pre-hospice consultative visit from a Participating Hospice              Aide Services or both may be covered on a 24 hour
Agency.) Covered Services are available on a 24-hour basis               continuous basis during Periods of Crisis but the care
to the extent necessary to meet the needs of individuals for             provided during these periods must be predominantly
care that is reasonable and necessary for the palliation and             nursing care.
management of Terminal Illness and related conditions.
Members can continue to receive covered Services that are            Respite Care Services are limited to an occasional basis and
not related to the palliation and management of the Terminal         to no more than five consecutive days at a time.
Illness from the appropriate provider.                               Members are allowed to change their Participating Hospice
Note: Hospice services provided by a Non-Participating               Agency only once during each Period of Care. Members can
hospice agency are not covered except in certain circum-             receive care for two 90-day periods followed by an unlimited
stances in counties in California in which there are no Par-         number of 60-day periods. The care continues through an-
ticipating Hospice Agencies and only when prior authorized           other Period of Care if the Participating Provider recertifies
by the Claims Administrator.                                         that the Member is Terminally Ill.
All of the Services listed below must be received through the        DEFINITIONS:
Participating Hospice Agency.                                        Bereavement Services – services available to the immediate
1.    Pre-hospice consultative visit regarding pain and              surviving family members for a period of at least one year
      symptom management, hospice and other care options             after the death of the Member. These services shall include
      including care planning (Members do not have to be             an assessment of the needs of the bereaved family and the
      enrolled in the Hospice Program to receive this Bene-          development of a care plan that meets these needs, both prior
      fit).                                                          to, and following the death of the Member.
2.    Interdisciplinary Team care with development and               Continuous Home Care – home care provided during a
      maintenance of an appropriate Plan of Care and man-            Period of Crisis. A minimum of 8 hours of continuous care,
      agement of Terminal Illness and related conditions.            during a 24-hour day, beginning and ending at midnight is
                                                                     required. This care could be 4 hours in the morning and an-
3.    Skilled Nursing Services, certified health aide Ser-           other 4 hours in the evening. Nursing care must be provided
      vices and homemaker Services under the supervision             for more than half of the period of care and must be provided
      of a qualified registered nurse.                               by either a registered nurse or licensed practical nurse.
4.    Bereavement Services.                                          Homemaker Services or Home Health Aide Services may be
                                                                     provided to supplement the nursing care. When fewer than 8
5.    Social Services/Counseling Services with medical               hours of nursing care are required, the services are covered as
      social services provided by a qualified social worker.         routine home care rather than Continuous Home Care.
      Dietary counseling, by a qualified provider, shall also
      be provided when needed.                                       Home Health Aide Services – services providing for the
                                                                     personal care of the Terminally Ill Member and the perform-
6.    Medical Direction with the medical director being also         ance of related tasks in the Member’s home in accordance
      responsible for meeting the general medical needs for          with the Plan of Care in order to increase the level of comfort
      the Terminal Illness of the Member to the extent that          and to maintain personal hygiene and a safe, healthy envi-
      these needs are not met by the Member’s other pro-             ronment for the patient.
      viders.
7.    Volunteer Services.


                                                                34
Homemaker Services – services that assist in the mainte-               year. A Period of Care starts the day the Member begins to
nance of a safe and healthy environment and services to en-            receive hospice care and ends when the 90- or 60-day period
able the Member to carry out the treatment plan.                       has ended.
Hospice Service or Hospice Program – a specialized form                Period of Crisis – a period in which the Member requires
of interdisciplinary health care that is designed to provide           continuous care to achieve palliation or management of acute
palliative care, alleviate the physical, emotional, social and         medical symptoms.
spiritual discomforts of a Member who is experiencing the
                                                                       Plan of Care – a written plan developed by the attending
last phases of life due to the existence of a Terminal Disease,
                                                                       physician and surgeon, the “medical director” (as defined
to provide supportive care to the primary caregiver and the
                                                                       under “Medical Direction”) or physician and surgeon desig-
family of the hospice patient, and which meets all of the fol-
                                                                       nee, and the Interdisciplinary Team that addresses the needs
lowing criteria:
                                                                       of a Member and family admitted to the Hospice Program.
1.   Considers the Member and the Member’s family in                   The Hospice shall retain overall responsibility for the devel-
     addition to the Member, as the unit of care.                      opment and maintenance of the Plan of Care and quality of
                                                                       Services delivered.
2.   Utilizes an Interdisciplinary Team to assess the physi-
     cal, medical, psychological, social and spiritual needs            Respite Care Services – short-term Inpatient care provided
     of the Member and their family.                                   to the Member only when necessary to relieve the family
                                                                       members or other persons caring for the Member.
3.   Requires the Interdisciplinary Team to develop an
     overall Plan of Care and to provide coordinated care              Skilled Nursing Services – nursing Services provided by or
     which emphasizes supportive Services, including, but              under the supervision of a registered nurse under a Plan of
     not limited to, home care, pain control, and short-term           Care developed by the Interdisciplinary Team and the Mem-
     Inpatient Services. Short-term Inpatient Services are             ber’s provider to the Member and his family that pertain to
     intended to ensure both continuity of care and appro-             the palliative, supportive services required by the Member
     priateness of services for those Members who cannot               with a Terminal Illness. Skilled Nursing Services include,
     be managed at home because of acute complications or              but are not limited to, Participant or Dependent assessment,
     the temporary absence of a capable primary caregiver.             evaluation, and case management of the medical nursing
                                                                       needs of the Member, the performance of prescribed medical
4.   Provides for the palliative medical treatment of pain
                                                                       treatment for pain and symptom control, the provision of
     and other symptoms associated with a Terminal Dis-
                                                                       emotional support to both the Member and his family, and
     ease, but does not provide for efforts to cure the dis-
                                                                       the instruction of caregivers in providing personal care to the
     ease.
                                                                       enrollee. Skilled Nursing Services provide for the continuity
5.   Provides for Bereavement Services following the                   of Services for the Member and his family and are available
     Member’s death to assist the family to cope with social           on a 24-hour on-call basis.
     and emotional needs associated with the death.
                                                                       Social Service/Counseling Services – those counseling and
6.   Actively utilizes volunteers in the delivery of Hospice           spiritual Services that assist the Member and his family to
     Services.                                                         minimize stresses and problems that arise from social, eco-
                                                                       nomic, psychological, or spiritual needs by utilizing appro-
7.   Provides Services in the Member’s home or primary
                                                                       priate community resources, and maximize positive aspects
     place of residence to the extent appropriate based on             and opportunities for growth.
     the medical needs of the Member.
                                                                       Terminal Disease or Terminal Illness – a medical condi-
8.   Is provided through a Participating Hospice.
                                                                       tion resulting in a prognosis of life of one year or less, if the
Interdisciplinary Team – the hospice care team that in-                disease follows its natural course.
cludes, but is not limited to, the Member and their family, a          Volunteer Services – services provided by trained hospice
physician and surgeon, a registered nurse, a social worker, a
                                                                       volunteers who have agreed to provide service under the di-
volunteer, and a spiritual caregiver.                                  rection of a hospice staff member who has been designated
Medical Direction – Services provided by a licensed physi-             by the Hospice to provide direction to hospice volunteers.
cian and surgeon who is charged with the responsibility of             Hospice volunteers may provide support and companionship
acting as a consultant to the Interdisciplinary Team, a con-           to the Member and his family during the remaining days of
sultant to the Member’s Participating Provider, as requested,          the Member’s life and to the surviving family following the
with regard to pain and symptom management, and liaison                Member’s death.
with physicians and surgeons in the community. For pur-
poses of this section, the person providing these Services
shall be referred to as the “medical director”.
Period of Care – the time when the Participating Provider
recertifies that the Member still needs and remains eligible
for hospice care even if the Member lives longer than one

                                                                  35
HOSPITAL BENEFITS (FACILITY SERVICES)                                  8.   Administration of blood and blood plasma, including the
(Other than Mental Health Benefits, Hospice Program                         cost of blood, blood plasma and blood processing.
Benefits, Skilled Nursing Facility Benefits and Dialysis               9.   X-ray examination and laboratory tests.
Center Benefits which are described elsewhere under
Covered Services)                                                      10. Radiation therapy, chemotherapy for cancer including
                                                                           catheterization, infusion devices, and associated drugs
Inpatient Services                                                         and supplies.
for Treatment of Illness or Injury
                                                                       11. Use of medical appliances and equipment.
1.   Any accommodation up to the Hospital's established
                                                                       12. Subacute Care.
     semi-private room rate, or, if Medically Necessary as
     certified by a Doctor of Medicine, the intensive care             13. Inpatient Services including general anesthesia and asso-
     unit.                                                                 ciated facility charges in connection with dental proce-
                                                                           dures when hospitalization is required because of an un-
2.   Use of operating room and specialized treatment rooms.
                                                                           derlying medical condition or clinical status and the
3.   In conjunction with a covered delivery, routine nursery               Member is under the age of seven or developmentally
     care for a newborn of the Participant, covered spouse or              disabled regardless of age or when the Member’s health
     Domestic Partner.                                                     is compromised and for whom general anesthesia is
                                                                           Medically Necessary regardless of age. Excludes dental
4.   Reconstructive Surgery is covered when there is no
                                                                           procedures and services of a dentist or oral surgeon.
     other more appropriate covered surgical procedure, and
     with regards to appearance, when Reconstructive Sur-              14. Medically Necessary Inpatient detoxification Services
     gery offers more than a minimal improvement in ap-                    required to treat potentially life-threatening symptoms of
     pearance. In accordance with the Women’s Health &                     acute toxicity or acute withdrawal are covered when a
     Cancer Rights Act, Reconstructive Surgery is covered                  covered Member is admitted through the emergency
     on either breast to restore and achieve symmetry incident             room, or when Medically Necessary Inpatient detoxifi-
     to a mastectomy, including treatment of physical com-                 cation is prior authorized by the Plan.
     plications of a mastectomy and lymphedemas. For cov-
     erage of prosthetic devices incident to a mastectomy, see         Outpatient Services
     Reconstructive Surgery under Professional (Physician)             for Treatment of Illness or Injury
     Benefits. Benefits will be provided in accordance with            1.   Medically Necessary Services provided in the Outpatient
     guidelines established by the Plan and developed in con-               Facility of a Hospital.
     junction with plastic and reconstructive surgeons.
                                                                       2.   Outpatient care provided by the admitting Hospital
     No benefits will be provided for the following surgeries               within 24 hours before admission, when care is related to
     or procedures unless for Reconstructive Surgery:                       the condition for which Inpatient admission was made.
         Surgery to excise, enlarge, reduce, or change the             3.   Radiation therapy and chemotherapy for cancer, includ-
         appearance of any part of the body;                                ing catheterization, infusion devices, and associated
         Surgery to reform or reshape skin or bone;                         drugs and supplies.

         Surgery to excise or reduce skin or connective tis-           4.   Reconstructive Surgery is covered when there is no
         sue that is loose, wrinkled, sagging, or excessive                 other more appropriate covered surgical procedure, and
         on any part of the body;                                           with regards to appearance, when Reconstructive Sur-
                                                                            gery offers more than a minimal improvement in ap-
         Hair transplantation; and                                          pearance. In accordance with the Women’s Health &
         Upper eyelid blepharoplasty without documented                     Cancer Rights Act, Reconstructive Surgery is covered
         significant visual impairment or symptomatology.                   on either breast to restore and achieve symmetry incident
                                                                            to a mastectomy, including treatment of physical com-
     This limitation shall not apply to breast reconstruction               plications of a mastectomy and lymphedemas. For cov-
     when performed subsequent to a mastectomy, including                   erage of prosthetic devices incident to a mastectomy, see
     surgery on either breast to achieve or restore symmetry.               Reconstructive Surgery under Professional (Physician)
5.   Surgical supplies, dressings and cast materials, and anes-             Benefits. Benefits will be provided in accordance with
     thetic supplies furnished by the Hospital.                             guidelines established by the Plan and developed in con-
                                                                            junction with plastic and reconstructive surgeons.
6.   Rehabilitation when furnished by the Hospital and ap-
     proved in advance by the Claims Administrator under its                No benefits will be provided for the following surgeries
     Benefits Management Program.                                           or procedures unless for Reconstructive Surgery:

7.   Drugs and oxygen.                                                          Surgery to excise, enlarge, reduce, or change the
                                                                                appearance of any part of the body;
                                                                                Surgery to reform or reshape skin or bone;

                                                                  36
         Surgery to excise or reduce skin or connective tis-               7.   dental and orthodontic Services that are an integral part
         sue that is loose, wrinkled, sagging, or excessive                     of Reconstructive Surgery for cleft palate repair.
         on any part of the body;
                                                                           No benefits are provided for:
         Hair transplantation; and
                                                                           1.   services performed on the teeth, gums (other than for
         Upper eyelid blepharoplasty without documented                         tumors and dental and orthodontic services that are an
         significant visual impairment or symptomatology.                       integral part of Reconstructive Surgery for cleft palate
                                                                                repair) and associated periodontal structures, routine care
     This limitation shall not apply to breast reconstruction
                                                                                of teeth and gums, diagnostic services, preventive or pe-
     when performed subsequent to a mastectomy, including
                                                                                riodontic services, dental orthoses and prostheses, in-
     surgery on either breast to achieve or restore symmetry.
                                                                                cluding hospitalization incident thereto;
5.   Outpatient Services including general anesthesia and
                                                                           2.   orthodontia (dental services to correct irregularities or
     associated facility charges in connection with dental
                                                                                malocclusion of the teeth) for any reason (except for or-
     procedures when performed in the Outpatient Facility of
                                                                                thodontic services that are an integral part of Recon-
     a Hospital because of an underlying medical condition
                                                                                structive Surgery for cleft palate repair), including
     or clinical status and the Member is under the age of
                                                                                treatment to alleviate TMJ;
     seven or developmentally disabled regardless of age or
     when the Member’s health is compromised and for                       3.   dental implants (endosteal, subperiosteal or transosteal);
     whom general anesthesia is Medically Necessary regard-
                                                                           4.   any procedure (e.g., vestibuloplasty) intended to prepare
     less of age. Excludes dental procedures and services of
                                                                                the mouth for dentures or for the more comfortable use
     a dentist or oral surgeon.
                                                                                of dentures;
Covered lab and X-ray Services provided in an Outpatient
                                                                           5.   alveolar ridge surgery of the jaws if performed primarily
Hospital setting are described under the Outpatient X-ray,
                                                                                to treat diseases related to the teeth, gums or periodontal
Pathology and Laboratory Benefits, Rehabilitation Benefits
                                                                                structures or to support natural or prosthetic teeth;
(Physical, Occupational and Respiratory Therapy), and
Speech Therapy Benefits sections.                                          6.   fluoride treatments except when used with radiation
                                                                                therapy to the oral cavity.
MEDICAL TREATMENT OF TEETH, GUMS, JAW                                      See Principal Limitations, Exceptions, Exclusions and Re-
JOINTS OR JAW BONES BENEFITS                                               ductions, General Exclusions for additional services that are
Benefits are provided for Hospital and professional Services               not covered.
provided for conditions of the teeth, gums or jaw joints and
                                                                           MENTAL HEALTH SERVICES
jaw bones, including adjacent tissues, only to the extent that
they are provided for:                                                     All non-Emergency Inpatient Mental Health Services and
                                                                           Outpatient Partial Hospitalization, Intensive Outpatient Care,
1.   the treatment of tumors of the gums;
                                                                           and Outpatient ECT Services must be prior authorized by the
2.   the treatment of damage to natural teeth caused solely by             Claims Administrator including those obtained outside of
     an Accidental Injury is limited to Medically Necessary                California. See the “Out-Of-Area Program: The BlueCard
     Services until the Services result in initial, palliative sta-        Program” section of this booklet for an explanation of how
     bilization of the Member as determined by the Plan;                   payment is made for out of state Services. For prior authori-
                                                                           zation, Participants should call the Customer Service tele-
     Note: Dental services provided after initial medical sta-
                                                                           phone number indicated on the back of the Member’s identi-
     bilization, prosthodontics, orthodontia, and cosmetic
                                                                           fication card. (See the Benefits Management Program sec-
     services are not covered. This Benefit does not include
                                                                           tion for complete information.)
     damage to the natural teeth that is not accidental, e.g.,
     resulting from chewing or biting.                                     Benefits are provided, as described below, for the diagnosis
                                                                           and treatment of Mental Health Conditions. All non-
3.   Medically Necessary non-surgical treatment (e.g., splint
                                                                           Emergency Inpatient Mental Health Services, Intensive Out-
     and Physical Therapy) of Temporomandibular Joint
                                                                           patient Care, all Outpatient Partial Hospitalization and Out-
     Syndrome (TMJ);
                                                                           patient ECT Services must be prior authorized by the Claims
4.   surgical and arthroscopic treatment of TMJ if prior his-              Administrator.
     tory shows conservative medical treatment has failed;
                                                                           The Copayments for covered Mental Health Services, if ap-
5.   Medically Necessary treatment of maxilla and mandible                 plicable, are shown on the Summary of Benefits.
     (jaw joints and jaw bones);
                                                                           Note: For all Inpatient Hospital care, except for Emergency
6.   orthognathic surgery (surgery to reposition the upper                 Services, failure to contact the Claims Administrator prior to
     and/or lower jaw) which is Medically Necessary to cor-                obtaining Services will result in the Participant being respon-
     rect a skeletal deformity ; or                                        sible for an Additional Payment, as outlined in the “Hospital
                                                                           and Skilled Nursing Facility Admissions” paragraphs of the


                                                                      37
Benefits Management Program section. For Outpatient Par-              ORTHOTICS BENEFITS
tial Hospitalization, Intensive Outpatient Care and Outpatient
ECT Services, failure to contact the Claims Administrator as          Benefits are provided for orthotic appliances, including:
described above or failure to follow the recommendations of           1.   shoes only when permanently attached to such appli-
the Claims Administrator will result in non-payment of ser-                ances;
vices by the Claims Administrator.
                                                                      2.   special footwear required for foot disfigurement which
No benefits are provided for Substance Abuse Conditions,                   includes, but is not limited to, foot disfigurement from
unless substance abuse coverage has been selected as an op-                cerebral palsy, arthritis, polio, spina bifida, and foot dis-
tional Benefit by your Employer, in which case an accompa-                 figurement caused by accident or developmental disabil-
nying insert provides the Benefit description, limitations and             ity;
Copayments. Note: Inpatient Services which are Medically
Necessary to treat the acute medical complications of detoxi-         3.   Medically Necessary knee braces for post-operative re-
fication are covered as part of the medical Benefits and are               habilitation following ligament surgery, instability due
not considered to be treatment of the Substance Abuse Con-                 to injury, and to reduce pain and instability for patients
dition itself.                                                             with osteoarthritis;
Benefits are provided for diagnosis and treatment by Hospi-           4.   Medically Necessary functional foot orthoses that are
tals, Doctors of Medicine, or Other Providers, subject to the              custom made rigid inserts for shoes, ordered by a physi-
following conditions and limitations:                                      cian or podiatrist, and used to treat mechanical problems
                                                                           of the foot, ankle or leg by preventing abnormal motion
1.   Inpatient Care                                                        and positioning when improvement has not occurred
     All Inpatient Hospital care or psychiatric day care must              with a trial of strapping or an over-the-counter stabiliz-
     be approved by the Claims Administrator, except for                   ing device;
     emergency care, as outlined in “Hospital and Skilled             5.   initial fitting and replacement after the expected life of
     Nursing Facility Admissions” of the Benefits Manage-                  the orthosis is covered.
     ment Program section. Residential care is not covered.
                                                                      Benefits are provided for orthotic devices for maintaining
     Note: See Hospital Benefits (Facility Services), Inpa-           normal Activities of Daily Living only. No benefits are pro-
     tient Services for Treatment of Illness or Injury for in-        vided for orthotic devices such as knee braces intended to
     formation on Medically Necessary Inpatient detoxifica-           provide additional support for recreational or sports activities
     tion.                                                            or for orthopedic shoes and other supportive devices for the
2.   Outpatient Facility and office care                              feet. No benefits are provided for backup or alternate items.
     Benefits are provided for Outpatient facility and office         Note: See the Diabetes Care Benefits section for devices,
     visits for Mental Health Conditions.                             equipment, and supplies for the management and treatment
                                                                      of diabetes.
     Benefits are provided for Services of licensed marriage
     and family therapists subject to these limitations and
     only upon referral by a Doctor of Medicine.
                                                                      OUTPATIENT PRESCRIPTION DRUGS BENEFITS
                                                                      Benefits are provided for Medically Necessary Outpatient
3.   Outpatient Hospital Partial Hospitalization, Intensive
                                                                      prescription Drugs, which meet all the requirements specified
     Outpatient Care and Outpatient ECT Services
                                                                      in this section, are prescribed by a Physician, and are ob-
     Benefits are provided for Hospital and professional Ser-         tained from a licensed pharmacy. Benefits are limited to
     vices in connection with Partial Hospitalization, Inten-         Medically Necessary Drugs which are approved by the Food
     sive Outpatient Care and ECT for the treatment of Men-           and Drug Administration (FDA), and which require a pre-
     tal Health Conditions.                                           scription under Federal or California law. Drug coverage is
                                                                      based on the use of the Claims Administrator’s Outpatient
4.   Psychological testing
                                                                      Prescription Drug Formulary, which is updated on an ongo-
     Psychological testing is a covered Benefit when pro-             ing basis by the Claims Administrator’s Pharmacy and
     vided to diagnose a Mental Health Condition.                     Therapeutics Committee. Non-Formulary Drugs may be
                                                                      covered subject to higher Copayments. Select Drugs and
No benefits are provided for:
                                                                      Drug dosages and most Specialty Drugs require prior au-
1.   telephone psychiatric consultations;                             thorization by the Claims Administrator for Medical Neces-
                                                                      sity, appropriateness of therapy or when effective, lower cost
2.   testing for intelligence or learning disabilities.               alternatives are available. Your Physician may request prior
The Copayments for covered Mental Health Services are                 authorization from the Claims Administrator. Coverage for
shown on the Summary of Benefits.                                     selected Drugs may be limited to a specific quantity as de-
                                                                      scribed in the section entitled “Limitation on Quantity of
                                                                      Drugs that May Be Obtained Per Prescription or Refill”.



                                                                 38
Outpatient prescription Drugs are subject to the Calendar                prescribing Drugs that are Medically Necessary and cost
Year Deductible.                                                         effective. The Formulary is updated periodically. If not oth-
                                                                         erwise excluded, the Formulary includes all Generic Drugs.
Outpatient Drug Formulary
                                                                         Generic Drugs — Drugs that (1) are approved by the Food
Medications are selected for inclusion in the Claims Admin-
                                                                         and Drug Administration (FDA) as a therapeutic equivalent
istrator’s Outpatient Drug Formulary based on safety, effi-
                                                                         to the Brand Name Drug, (2) contain the same active ingredi-
cacy, FDA bioequivalency data and then cost. New drugs
                                                                         ent as the Brand Name Drug, and (3) cost less than the Brand
and clinical data are reviewed regularly to update the Formu-
                                                                         Name Drug equivalent.
lary. Drugs considered for inclusion or exclusion from the
Formulary are reviewed by the Claims Administrator’s                     Non-Formulary Drugs — Drugs determined by the Claims
Pharmacy and Therapeutics Committee during scheduled                     Administrator’s Pharmacy and Therapeutics Committee as
meetings four times a year.                                              being duplicative or as having preferred Formulary Drug
                                                                         alternatives available. Benefits are provided for Non-
Members may call the Claims Administrator Customer Ser-
                                                                         Formulary Drugs and are always subject to the Non-
vice department at the number listed on their Claims Admin-
                                                                         Formulary Copayment.
istrator Identification Card to inquire if a specific drug is in-
cluded in the Formulary. The Customer Service department                 Non-Participating Pharmacy — a pharmacy which does
can also provide Members with a printed copy of the Formu-               not participate in the Claims Administrator Pharmacy Net-
lary. Members may also access the Formulary through the                  work.
Claims           Administrator        web          site        at
                                                                         Participating Pharmacy — a pharmacy which participates
http://www.blueshieldca.com.
                                                                         in the Claims Administrator Pharmacy Network. These Par-
Benefits may be provided for Non-Formulary Drugs subject                 ticipating Pharmacies have agreed to a contracted rate for
to higher Copayments.                                                    covered prescriptions for the Claims Administrator Members
                                                                         and Dependents.
This benefit includes access to the Claims Administrator’s
Participating Pharmacy Network. By presenting your Claims                To select a Participating Pharmacy, you may go to
Administrator ID card to a Participating Pharmacy you will               http://www.blueshieldca.com or call the toll-free Customer
pay the Claims Administrator’s contracted rate for covered               Service number on your Claims Administrator Identification
medication. This will significantly reduce your out of pocket            Card.
costs for covered medications. Please see section entitled
“Obtaining Outpatient Prescription Drugs at a Participating              Specialty Drugs - Specialty Drugs are specific Drugs used to
Pharmacy” for more details.                                              treat complex or chronic conditions which usually require
                                                                         close monitoring such as multiple sclerosis, hepatitis, rheu-
Definitions                                                              matoid arthritis, cancer, and other conditions that are difficult
                                                                         to treat with traditional therapies. Specialty Drugs are listed
Brand Name Drugs — Drugs which are FDA approved
                                                                         in the Claims Administrator’s Outpatient Drug Formulary.
either (1) after a new drug application, or (2) after an abbre-          Specialty Drugs may be self-administered in the home by
viated new drug application and which has the same brand                 injection by the patient or family member (subcutaneously or
name as that of the manufacturer with the original FDA ap-               intramuscularly), by inhalation, orally or topically. Infused or
proval.                                                                  Intravenous (IV) medications are not included as Specialty
Drugs — (1) Drugs which are approved by the Food and                     Drugs. These Drugs may also require special handling, spe-
Drug Administration (FDA), requiring a prescription either               cial manufacturing processes, and may have limited prescrib-
by Federal, (2) Insulin, and disposable hypodermic Insulin               ing or limited pharmacy availability. Specialty Drugs must
needles and syringes (3) pen delivery systems for the admini-            be considered safe for self-administration by the Claims Ad-
                                                                         ministrator’s Pharmacy and Therapeutics Committee, be ob-
stration of Insulin as Medically Necessary, (4) diabetic test-
                                                                         tained from a the Claims Administrator Specialty Pharmacy
ing supplies (including lancets, lancet puncture devices, and
                                                                         and may require prior authorization for Medical Necessity by
blood and urine testing strips and test tablets), (5) oral con-
                                                                         the Claims Administrator.
traceptives and diaphragms, and (6) smoking cessation Drugs
which require a prescription, (7) inhalers and inhaler spacers           Specialty Pharmacy Network – select Participating Phar-
for the management and treatment of asthma.                              macies contracted by the Claims Administrator to provide
                                                                         covered Specialty Drugs. These pharmacies offer 24-hour
Note: No prescription is necessary to purchase the items                 clinical services and provide prompt home delivery of Spe-
shown in (2), (3) and (4) above; however, in order to be cov-            cialty Drugs.
ered these items must be ordered by your Physician.
                                                                         To select a Specialty Pharmacy, you may go to
Formulary — A comprehensive list of Drugs maintained by                  http://www.blueshieldca.com or call the toll-free Customer
the Claims Administrator’s Pharmacy and Therapeutics                     Service number on your the Claims Administrator Identifica-
Committee for use under the Claims Administrator Prescrip-               tion Card.
tion Drug Program which is designed to assist Physicians in

                                                                    39
Obtaining Outpatient Prescription Drugs at a                           request” on the form to the Claims Administrator Pharmacy
Participating Pharmacy                                                 Services -Emergency Claims, P.O. Box 7168, San Francisco,
                                                                       CA 94120. After the Calendar Year Deductible amount has
To obtain prescription Drugs at a Participating Pharmacy, the
                                                                       been satisfied, the Member will be reimbursed the purchase
Member must present his Claims Administrator Identifica-
                                                                       price of covered prescription Drug(s) minus any applicable
tion Card. Note: Except for covered emergencies and Drugs
                                                                       Copayment(s). Claim forms may be obtained from the
for emergency contraception, claims for drugs obtained with-
                                                                       Claims Administrator Service Center. Claims must be re-
out using the Claims Administrator Identification Card will
                                                                       ceived within 1 year from the date of service to be considered
be denied.
                                                                       for payment.
With the presentation of the Claims Administrator Identifica-
tion Card, outpatient prescription Drugs obtained at a Partici-        Obtaining Outpatient Prescription Drugs through
pating Pharmacy, or Specialty Drugs obtained from a Spe-               the Mail Service Prescription Drug Program
cialty Pharmacy through the use of your Claims Administra-             For the Member’s convenience, when Drugs have been pre-
tor Identification Number, are paid as shown in the Summary            scribed for a chronic condition and the Member’s medication
of Benefits.                                                           dosage has been stabilized, he may obtain the Drug through
Once the Calendar Year Deductible has been satisfied, the              mail service prescription drug program.
Member is responsible for paying the applicable Copayment              To obtain prescription Drugs through the mail service pro-
for each new and refill prescription Drug. The pharmacist              gram, the Member should submit the applicable mail service
will collect from the Member the applicable Copayment at
                                                                       Copayment*, order form, and his Claims Administrator
the time the Drugs are obtained.
                                                                       Member number to the address indicated on the mail service
Note: If the Participating Pharmacy contracted rate charged            envelope. Members should allow up to 14 days to receive
by the Participating Pharmacy is less than or equal to the             the drugs. The Member’s Physician must indicate a prescrip-
Member’s Copayment, the Member will only be required to                tion quantity which is equal to the amount to be dispensed.
pay the Participating Pharmacy’s contracted rate.
                                                                       Specialty Drugs, except for Insulin, are not available through
If the Member requests a Brand Name Drug when a Generic                the mail service prescription drug program.
Drug equivalent is available, the Member is responsible for
paying the difference between the Participating Pharmacy               *Until the Calendar Year Deductible is satisfied, the Member
contracted rate for the Brand Name Drug and its Generic                is responsible for payment 100% of the contracted rate for
Drug equivalent, as well as the applicable Generic Drug Co-            the Drug to the mail service pharmacy prior to your prescrip-
payment. This difference in cost that the Member must pay              tion being sent to you.
is not applied to the Calendar Year Deductible and is not              Outpatient prescription Drugs obtained through the mail ser-
included in the Calendar Year maximum out-of-pocket re-                vice prescription drug program are paid as shown in the
sponsibility calculations.                                             Summary of Benefits.
If the prescription specifies a Brand Name Drug and the pre-           Once the Calendar Year Deductible has been satisfied, the
scribing Physician has written “Dispense As Written” or “Do            Member is responsible for the applicable mail service pre-
Not Substitute” on the prescription, or if a Generic Drug              scription drug Copayment for each new or refill prescription
equivalent is not available, the Member is responsible for             Drug.
paying the applicable Brand Name Drug Copayment.
                                                                       Note: If the Participating Pharmacy contracted rate is less
Obtaining Outpatient Prescription Drugs at a                           than or equal to the Member’s Copayment, the Member will
Non-Participating Pharmacy                                             only be required to pay the Participating Pharmacy’s con-
To obtain prescription Drugs at a Non-Participating Phar-              tracted rate.
macy, the Member must first pay all charges for the prescrip-          If the Member requests a Mail Service Brand Name Drug
tion and submit a completed Prescription Drug Claim Form               when a Mail Service Generic Drug equivalent is available,
for reimbursement. After the Calendar Year Deductible                  the Member is responsible for paying the difference between
amount has been satisfied, the Member will be reimbursed as            the contracted rate for the Mail Service Brand Name Drug
shown on the Summary of Benefits. Claims must be re-                   and its Mail Service Generic Drug equivalent, as well as the
ceived within 1 year from the date of service to be considered         applicable Mail Service Generic Drug Copayment. This dif-
for payment.                                                           ference in cost that the Member must pay is not applied to the
Drugs obtained at a Non-Participating Pharmacy for a cov-              Calendar Year Deductible and is not included in the Calendar
ered emergency, including Drugs for emergency contracep-               Year maximum out-of-pocket responsibility calculations.
tion.                                                                  If the prescription specifies a Mail Service Brand Name Drug
When prescription Drugs are obtained at a Non-Participating            and the prescribing Physician has written “Dispense As Writ-
Pharmacy due to a covered emergency, the Member must                   ten” or “Do Not Substitute” on the prescription, or if a Mail
first pay all charges for the prescription, and then submit a          Service Generic Drug equivalent is not available, the Mem-
completed Prescription Drug Claim Form noting “emergency

                                                                  40
ber is responsible for paying the applicable Mail Service             2. Mail service prescription Drugs are limited to a
Brand Name Drug Copayment.                                               quantity not to exceed a 90-day supply. If the
You are responsible for payment of the Deductible and/or                 Member’s Physician indicates a prescription
Copayment amount for the Drug to the mail service phar-                  quantity of less than a 90-day supply, that
macy prior to your prescription being sent to you. To obtain
                                                                         amount will be dispensed, and refill authoriza-
the Participating Pharmacy contracted rate amount, please
contact the mail service pharmacy at 1-866-346-7200. The                 tions cannot be combined to reach a 90-day
TTY telephone number is 1-866-346-7197.                                  supply.
Submitting a Claim                                                    3. Prescriptions may be refilled at a frequency
The submission of a prescription drug claim is required for
                                                                         that is considered to be Medically Necessary.
reimbursement if you utilized a Non-Participating Pharmacy.           Exclusions
Each claim submission should contain your name, home
                                                                      No benefits are provided under the Outpatient Pre-
address, Member number, the patient's name and a copy of
your pharmacy label receipt(s) for the prescription Drug(s)           scription Drugs Benefit for or on account of the
being claimed. Prescription drug claim forms are provided             following (please note, certain services excluded
upon request from the Claims Administrator ld at the address          below may be covered under other bene-
and telephone number as listed at the back of this booklet.           fits/portions of this booklet – you should refer to
These     forms     are   also    available     online    at          the applicable section to determine if drugs are
www.blueshieldca.com. Prescription drug claim forms should            covered under that Benefit):
be submitted to:
         Argus Health Systems, Inc.
                                                                      1. Any drugs provided or administered while the
         Department 191                                                  Member is an Inpatient, or in a Physician’s of-
         PO Box 419019                                                   fice (see the Professional (Physician) Benefits
         Kansas City, MO 64141-6019                                      and Hospital Benefits sections);
Claims must be received within 1 year from the date of ser-           2. Take home drugs received from a Hospital,
vice to be considered for payment.
                                                                         convalescent home, Skilled Nursing Facility,
Prior Authorization Process for Select Formulary,                        or similar facility (see the Hospital Benefits
Non-Formulary and Specialty Drugs                                        and Skilled Nursing Facility Benefits sections);
Select Formulary Drugs, as well as most Specialty Drugs
may require prior authorization for Medical Necessity. Se-            3. Drugs (except as specifically listed as covered
lect Non-Formulary Drugs may require prior authorization                 under this Outpatient Prescription Drugs Bene-
for Medical Necessity, and to determine if lower cost alterna-           fit) which can be obtained without a prescrip-
tives are available and just as effective. Your Physician may            tion or for which there is a non-prescription
request prior authorization by submitting supporting informa-
                                                                         drug that is the identical chemical equivalent
tion to the Claims Administrator. Once all required support-
ing information is received, prior authorization approval or             (i.e., same active ingredient and dosage) to a
denial, based upon Medical Necessity, is provided within 5               prescription drug;
business days or within 72 hours for an expedited review.
                                                                      4. Drugs for which the Member is not legally ob-
Limitation on Quantity of Drugs that May                                 ligated to pay, or for which no charge is made;
Be Obtained Per Prescription or Refill                                5. Drugs that are considered Experimental or In-
1. Outpatient prescription Drugs are limited to a                        vestigational in nature;
   quantity not to exceed a 30-day supply. If a                       6. Medical devices or supplies, except as specifi-
   prescription Drug is packaged only in supplies                        cally listed as covered herein (see the Durable
   exceeding 30 days, the applicable retail Co-                          Medical Equipment Benefits, Orthotics Bene-
   payment will be assessed for each 30-day sup-                         fits, and Prosthetic Appliances Benefits sec-
   ply. Some prescriptions are limited to a maxi-                        tions). This exclusion also includes topically
   mum allowable quantity based on Medical Ne-                           applied prescription preparations that are ap-
   cessity and appropriateness of therapy as de-                         proved by the FDA as medical devices;
   termined by the Claims Administrator’s Phar-
   macy and Therapeutics Committee.                                   7. Blood or blood products (see the Hospital
                                                                         Benefits section);

                                                                 41
8. Drugs when prescribed for cosmetic purposes,             17. Drugs prescribed for treatment of dental condi-
   such as those used to retard or reverse the ef-              tions. This exclusion shall not apply to antibi-
   fects of skin aging or to treat hair loss;                   otics prescribed to treat infection nor to medi-
                                                                cations prescribed to treat pain;
9. Dietary or nutritional products (see the Home
   Health Care Benefits, Home Infusion/Home                 18. Drugs obtained from a Pharmacy not licensed
   Injectable Therapy Benefits, and PKU Related                 by the National Association of Boards of
   Formulas and Special Food Products Benefits                  Pharmacies, unless medically necessary for a
   sections);                                                   covered Emergency;
10. Injectable drugs which are not self-                    19. Immunizations and vaccinations by any mode
    administered, and all injectable drugs for the              of administration (oral, injection or otherwise)
    treatment of infertility. Other injectable medi-            solely for the purpose of travel;
    cations may be covered under the Home                   20. Drugs packaged in convenience kits that in-
    Health Care Benefits, Home Infusion/Home                    clude non-prescription convenience items,
    Injectable Therapy Benefits, PKU Related                    unless the Drug is not otherwise available
    Formulas and Special Food Products Benefits,                without the non-prescription components.
    Hospice Program Benefits, and Family Plan-                  This exclusion shall not apply to items used for
    ning Benefits sections;                                     the administration of diabetes or asthma Drugs.
11. Appetite suppressants or drugs for body weight
    reduction except when Medically Necessary               OUTPATIENT X-RAY, PATHOLOGY AND
    for the treatment of morbid obesity. In such
    cases the drug will be subject to prior authori-        LABORATORY BENEFITS
    zation from Blue Shield;                                Benefits are provided for diagnostic X-ray Services, diagnos-
                                                            tic examinations, clinical pathology, and laboratory Services,
12. Drugs when prescribed for smoking cessation             when provided to diagnose illness or injury. Routine labora-
    purposes (over the counter or by prescription),         tory Services performed as part of a preventive health screen-
    except to the extent that smoking cessation             ing are covered under the Preventive Health Benefits section.
    prescription Drugs are specifically listed as           Benefits are provided for genetic testing for certain condi-
    covered under the “Drugs” definition in this            tions when the Member has risk factors such as family his-
    benefit description;                                    tory or specific symptoms. The testing must be expected to
                                                            lead to increased or altered monitoring for early detection of
13. Contraceptive devices (except diaphragms),              disease, a treatment plan or other therapeutic intervention and
    injections or implants, except as specifically          determined to be Medically Necessary and appropriate in
                                                            accordance with the Claims Administrator medical policy.
    listed;
                                                            (Note: See the section on Pregnancy and Maternity Care
14. Compounded medications if: (1) there is a               Benefits for genetic testing for prenatal diagnosis of genetic
    medically appropriate Formulary alternative,            disorders of the fetus.)
    or, (2) there are no FDA-approved indications.          See the Radiological Procedures Benefits (Requiring Prior
    Compounded medications that do not include              Authorization) and Benefits Management Program section(s)
                                                            for radiological procedures which require prior authorization
    at least one Drug, as defined, are not covered;
                                                            by the Plan.
15. Replacement of lost, stolen or destroyed pre-
    scription Drugs;                                        PKU RELATED FORMULAS AND SPECIAL FOOD
                                                            PRODUCTS BENEFITS
16. Pharmaceuticals that are reasonable and neces-
    sary for the palliation and management of               Benefits are provided for enteral formulas, related medical
                                                            supplies, and Special Food Products that are Medically Nec-
    Terminal Illness and related conditions if they         essary for the treatment of phenylketonuria (PKU) to avert
    are provided to a Member enrolled in a Hos-             the development of serious physical or mental disabilities or
    pice Program through a Participating Hospice            to promote normal development or function as a consequence
    Agency;                                                 of PKU. All Benefits must be prior authorized by the Claims
                                                            Administrator and must be prescribed and/or ordered by the
                                                            appropriate health care professional.


                                                       42
PODIATRIC BENEFITS                                                      Professional Services by providers other than Physicians are
                                                                        described elsewhere under Covered Services.
Benefits are provided for office visits, surgical procedures,
and other covered Services customarily provided by a li-                Covered lab and X-ray Services provided in conjunction with
censed doctor of podiatric medicine. Covered surgical pro-              these Professional Services listed below, are described under
cedures provided in conjunction with this Benefit, are de-              the Outpatient X-ray, Pathology and Laboratory Benefits
scribed under the Professional (Physician) Benefits section.            section.
Covered lab and x-ray Services provided in conjunction with             Note: A Preferred Physician may offer extended hour and
this Benefit are described under the Outpatient X-ray, Pa-              urgent care Services on a walk-in basis in a non-hospital set-
thology and Laboratory Benefits section.                                ting such as the Physician’s office or an urgent care center.
                                                                        Services received from a Preferred Physician at an extended
PREGNANCY AND MATERNITY CARE                                            hours facility will be reimbursed as Physician Office Visits.
BENEFITS                                                                A list of urgent care providers may be found in the Preferred
                                                                        Provider Directory or the Online Physician Directory located
Benefits are provided for pregnancy and complications of                at http://www.blueshieldca.com.
pregnancy, including prenatal diagnosis of genetic disorders
of the fetus by means of diagnostic procedures in cases of              Benefits are provided for Services of Physicians for treatment
high-risk pregnancy, and post-delivery care. (Note: See the             of illness or injury, and for treatment of physical complica-
section on Outpatient X-ray, Pathology and Laboratory                   tions of a mastectomy, including lymphedemas, as indicated
Benefits for information on coverage of other genetic testing           below.
and diagnostic procedures.) No benefits are provided for                1.   Visits to the office, beginning with the first visit;
services after termination of coverage under this Plan unless
the Member qualifies for an extension of Benefits as de-                2.   Services of consultants, including those for second
scribed elsewhere in this booklet.                                           medical opinion consultations;

For Outpatient routine newborn circumcisions, for the pur-              3.   Mammography and Papanicolaou tests or other FDA
poses of this Benefit, routine newborn circumcisions are cir-                (Food and Drug Administration) approved cervical can-
cumcisions performed within 31 days of birth unrelated to                    cer screening tests;
illness or injury. Routine circumcisions after this time period         4.   Asthma self-management training and education to en-
are covered for sick babies when authorized by the Claims                    able a Participant to properly use asthma-related medica-
Administrator.                                                               tion and equipment such as inhalers, spacers, nebulizers
Note: The Newborns’ and Mothers’ Health Protection Act                       and peak flow monitors;
requires group health plans to provide a minimum Hospital               5.   Visits to the home, Hospital, Skilled Nursing Facility
stay for the mother and newborn child of 48 hours after a                    and Emergency Room;
normal, vaginal delivery and 96 hours after a C-section
unless the attending Physician, in consultation with the                6.   Routine newborn care in the Hospital including physical
mother, determines a shorter Hospital length of stay is ade-                 examination of the baby and counseling with the mother
quate.                                                                       concerning the baby during the Hospital stay;

If the Hospital stay is less than 48 hours after a normal, vagi-        7.   Surgical procedures. When multiple surgical procedures
nal delivery or less than 96 hours after a C-section, a follow-              are performed during the same operation, Benefits for
up visit for the mother and newborn within 48 hours of dis-                  the secondary procedure(s) will be determined based on
charge is covered when prescribed by the treating Physician.                 the Plan’s Medical Policy. No benefits are provided for
This visit shall be provided by a licensed health care provider              secondary procedures which are incidental to, or an inte-
whose scope of practice includes postpartum and newborn                      gral part of, the primary procedure;
care. The treating Physician, in consultation with the mother,          8.   Reconstructive Surgery is covered when there is no
shall determine whether this visit shall occur at home, the                  other more appropriate covered surgical procedure, and
contracted facility, or the Physician’s office.                              with regards to appearance, when Reconstructive Sur-
                                                                             gery offers more than a minimal improvement in ap-
PREVENTIVE HEALTH BENEFITS                                                   pearance. In accordance with the Women’s Health &
                                                                             Cancer Rights Act, Reconstructive Surgery, and surgi-
Preventive Health Services, as defined, are covered.
                                                                             cally implanted and non-surgically implanted prosthetic
PROFESSIONAL (PHYSICIAN) BENEFITS                                            devices (including prosthetic bras), are covered on either
(Other than Preventive Health Benefits, Mental Health                        breast to restore and achieve symmetry incident to a
Benefits, Hospice Program Benefits and Dialysis Center                       mastectomy, and treatment of physical complications of
Benefits which are described elsewhere under Covered                         a mastectomy, including lymphedemas. Benefits will be
Services)                                                                    provided in accordance with guidelines established by
                                                                             the Plan and developed in conjunction with plastic and
                                                                             reconstructive surgeons.


                                                                   43
     No benefits will be provided for the following surgeries           not be covered under your Plan if your Employer provides
     or procedures unless for Reconstructive Surgery:                   supplemental Benefits for vision care that cover contact
                                                                        lenses through a vision plan purchased through the Claims
         Surgery to excise, enlarge, reduce, or change the
                                                                        Administrator. There is no coordination of benefits between
         appearance of any part of the body;
                                                                        the health Plan and the vision plan for these Benefits.
         Surgery to reform or reshape skin or bone;
                                                                        For surgically implanted and other prosthetic devices (includ-
         Surgery to excise or reduce skin or connective tis-            ing prosthetic bras) provided to restore and achieve symme-
         sue that is loose, wrinkled, sagging, or excessive             try incident to a mastectomy, see Reconstructive Surgery
         on any part of the body;                                       under Professional (Physician) Benefits. Surgically implanted
                                                                        prostheses including, but not limited to, Blom-Singer and
         Hair transplantation; and                                      artificial larynx prostheses for speech following a laryngec-
         Upper eyelid blepharoplasty without documented                 tomy are covered as a surgical professional benefit.
         significant visual impairment or symptomatology.
                                                                        RADIOLOGICAL PROCEDURES BENEFITS
     This limitation shall not apply to breast reconstruction           (REQUIRING PRIOR AUTHORIZATION)
     when performed subsequent to a mastectomy, including
     surgery on either breast to achieve or restore symmetry.           The following radiological procedures, when performed on
                                                                        an Outpatient, non-emergency basis, require prior authoriza-
9.   Chemotherapy for cancer, including catheterization, and
                                                                        tion by the Plan under the Benefits Management Program.
     associated drugs and supplies;
                                                                        Failure to obtain this authorization will result in the Service
10. Extra time spent when a Physician is detained to treat a            being paid at a reduced amount or may result in non-payment
    Participant in critical condition;                                  for procedures which are determined not to be covered Ser-
                                                                        vices.
11. Necessary preoperative treatment;
                                                                        See the Benefits Management Program section for complete
12. Treatment of burns.                                                 information.

PROSTHETIC APPLIANCES BENEFITS                                          1.   CT (Computerized Tomography) scans;

Medically Necessary Prostheses for Activities of Daily Liv-             2.   MRIs (Magnetic Resonance Imaging);
ing are covered. Benefits are provided at the most cost effec-          3.   MRAs (Magnetic Resonance Angiography);
tive level of care that is consistent with professionally recog-
nized standards of practice. If there are two or more profes-           4.   PET (Positron Emission Tomography) scans; and,
sionally recognized appliances equally appropriate for a con-           5.   any cardiac diagnostic procedure utilizing Nuclear Medi-
dition, Benefits will be based on the most cost effective ap-                cine.
pliance. See General Exclusions under the Principal Limita-
tions, Exceptions, Exclusions and Reductions section for a
                                                                        REHABILITATION BENEFITS (PHYSICAL,
listing of excluded speech and language assistance devices.
                                                                        OCCUPATIONAL AND RESPIRATORY THERAPY)
Benefits are provided for Medically Necessary Prostheses for
Activities of Daily Living, including the following:                    Benefits are provided for Outpatient Physical, Occupational,
                                                                        and/or Respiratory Therapy pursuant to a written treatment
1.   Surgically implanted prostheses including, but not lim-            plan and when rendered in the provider’s office or Outpatient
     ited to, Blom-Singer and artificial larynx prostheses for          department of a Hospital. Benefits for Speech Therapy are
     speech following a laryngectomy;                                   described in the section on Speech Therapy Benefits. The
2.   Artificial limbs and eyes;                                         Claims Administrator reserves the right to periodically re-
                                                                        view the provider’s treatment plan and records. If the Claims
3.   Supplies necessary for the operation of Prostheses;                Administrator determines that continued treatment is not
4.   Initial fitting and replacement after the expected life of         Medically Necessary and not provided with the expectation
     the item;                                                          that the patient has restorative potential pursuant to the treat-
                                                                        ment plan, the Claims Administrator will notify the Partici-
5.   Repairs, even if due to damage.                                    pant of this determination and benefits will not be provided
                                                                        for services rendered after the date of the written notification.
No benefits are provided for wigs for any reason or any type
of speech or language assistance devices (except as specifi-            Services provided by a chiropractor are not included in this
cally provided). No benefits are provided for backup or alter-          Rehabilitation Benefit. See the section on Chiropractic
nate items.                                                             Benefits.
Benefits are provided for contact lenses, if Medically Neces-           Note: Outpatient Rehabilitation Services are limited to a
sary to treat eye conditions such as keratoconus, keratitis             combined per Member per Calendar Year Benefit maximum
sicca or aphakia following cataract surgery when no intraocu-           with chiropractic Services as shown on the Summary of
lar lens has been implanted. Note: These contact lenses will            Benefits.


                                                                   44
Note: See the Home Health Care Benefits and Hospice Pro-               Note: See the Home Health Care Benefits section for infor-
gram Benefits sections for information on coverage for Re-             mation on coverage for Speech Therapy Services rendered in
habilitation Services rendered in the home.                            the home.
Note: Covered lab and X-ray Services provided in conjunc-              See the Inpatient Services for Treatment of Illness or Injury
tion with this Benefit are paid as shown under the Outpatient          section for information on Inpatient Benefits and the Hospice
X-ray, Pathology and Laboratory Benefits section.                      Program Benefits section.

SKILLED NURSING FACILITY BENEFITS                                      TRANSPLANT BENEFITS – CORNEA, KIDNEY OR
(Other than Hospice Program Benefits, which are de-                    SKIN
scribed elsewhere under Covered Services.)
                                                                       Benefits are provided for Hospital and professional Services
Benefits are provided for Medically Necessary Services pro-            provided in connection with human organ transplants only to
vided by a Skilled Nursing Facility Unit of a Hospital or by a         the extent that:
free-standing Skilled Nursing Facility.
                                                                       1.   they are provided in connection with the transplant of a
Benefits are provided for confinement in a Skilled Nursing                  cornea, kidney, or skin; and
Facility or Skilled Nursing Facility Unit of a Hospital up to
the Benefit maximum as shown in the Summary of Benefits.               2.   the recipient of such transplant is a Participant or De-
The Benefit maximum is per Member per Calendar Year,                        pendent.
except that room and board charges in excess of the facility's         Benefits are provided for Services incident to obtaining the
established semi-private room rate are excluded.                       human organ transplant material from a living donor or an
                                                                       organ transplant bank.
SPEECH THERAPY BENEFITS
Outpatient Benefits for Speech Therapy Services are covered            TRANSPLANT BENEFITS - SPECIAL
when diagnosed and ordered by a Physician and provided by
an appropriately licensed speech therapist, pursuant to a writ-        Benefits are provided for certain procedures, listed below,
ten treatment plan for an appropriate time to: (1) correct or          only if (1) performed at a Special Transplant Facility con-
improve the speech abnormality, or (2) evaluate the effec-             tracting with the Claims Administrator to provide the proce-
tiveness of treatment, and when rendered in the provider’s             dure or in the case of Members accessing this Benefit outside
office or Outpatient department of a Hospital. Before initial          of California, the procedure is performed at a transplant facil-
services are provided, you or your provider should determine           ity designated by the Claims Administrator, (2) prior authori-
if the proposed treatment will be covered by following the             zation is obtained, in writing, from the Claims Administra-
Claims Administrator’s prior authorization procedures. (See            tor's Medical Director and (3) the recipient of the transplant
the section on the Benefits Management Program.)                       is a Participant or Dependent.

Services are provided for the correction of, or clinically sig-        The Claims Administrator reserves the right to review all
nificant improvement of, speech abnormalities that are the             requests for prior authorization for these Special Transplant
likely result of a diagnosed and identifiable medical condi-           Benefits, and to make a decision regarding benefits based on
tion, illness, or injury to the nervous system or to the vocal,        (1) the medical circumstances of each Member, and (2) con-
swallowing, or auditory organs.                                        sistency between the treatment proposed and the Claims
                                                                       Administrator medical policy. Failure to obtain prior written
Continued Outpatient Benefits will be provided for Medi-               authorization as described above and/or failure to have the
cally Necessary Services as long as continued treatment is             procedure performed at a contracting Special Transplant Fa-
Medically Necessary, pursuant to the treatment plan, and               cility will result in denial of claims for this Benefit.
likely to result in clinically significant progress as measured
by objective and standardized tests. The provider’s treatment          The following procedures are eligible for coverage under this
plan and records will be reviewed periodically. When con-              provision:
tinued treatment is not Medically Necessary pursuant to the            1.   Human heart transplants;
treatment plan, not likely to result in additional clinically
significant improvement, or no longer requires skilled ser-            2.   Human lung transplants;
vices of a licensed speech therapist, the Member will be noti-         3.   Human heart and lung transplants in combination;
fied of this determination and benefits will not be provided
for services rendered after the date of written notification.          4.   Human liver transplants;
Except as specified above and as stated under the Home                 5.   Human kidney and pancreas transplants in combination;
Health Care Benefits and Hospice Program Benefits sections,            6.   Human bone marrow transplants; including autologous
no Outpatient benefits are provided for Speech Therapy,                     bone marrow transplantation (ABMT) or autologous pe-
speech correction, or speech pathology services.                            ripheral stem cell transplantation used to support high-
                                                                            dose chemotherapy when such treatment is Medically
                                                                            Necessary and is not Experimental or Investigational;

                                                                  45
7.   Pediatric human small bowel transplants;                             supplement provides the Benefit description,
8.   Pediatric and adult human small bowel and liver trans-               limitations and Copayments;
     plants in combination.
                                                                      8. for hearing aids, except as specifically pro-
Benefits are provided for Services incident to obtaining the             vided under Prosthetic Appliances Benefits;
transplant material from a living donor or an organ transplant
bank.                                                                 9. for eye refractions, surgery to correct refractive
                                                                         error (such as but not limited to radial keratot-
PRINCIPAL LIMITATIONS, EXCEPTIONS,                                       omy, refractive keratoplasty), lenses and
EXCLUSIONS AND REDUCTIONS                                                frames for eyeglasses, and contact lenses ex-
                                                                         cept as specifically listed under Prosthetic Ap-
GENERAL EXCLUSIONS                                                       pliances Benefits, and video-assisted visual
                                                                         aids or video magnification equipment for any
Unless exceptions to the following are specifically
                                                                         purpose;
made elsewhere in this booklet, no benefits are
provided for the following services:                                  10. for any type of communicator, voice enhancer,
                                                                          voice prosthesis, electronic voice producing
1. for or incident to hospitalization or confine-
                                                                          machine, or any other language assistive de-
   ment in a pain management center to treat or
                                                                          vices, except as specifically listed under Pros-
   cure chronic pain, except as may be provided
                                                                          thetic Appliances Benefits;
   through a Participating Hospice Agency and
   except as Medically Necessary;                                     11. for routine physical examinations, except as
                                                                          specifically listed under Preventive Health
2. for Rehabilitation Services, except as specifi-
                                                                          Benefits, or for immunizations and vaccina-
   cally provided in the Inpatient Services for
                                                                          tions by any mode of administration (oral, in-
   Treatment of Illness or Injury, Home Health
                                                                          jection or otherwise) solely for the purpose of
   Care Benefits, Rehabilitation Benefits (Physi-
                                                                          travel, or for examinations required for licen-
   cal, Occupational and Respiratory Therapy)
                                                                          sure, employment, or insurance unless the ex-
   and Hospice Program Benefits sections;
                                                                          amination is substituted for the Annual Health
3. for or incident to services rendered in the home                       Appraisal Exam;
   or hospitalization or confinement in a health
                                                                      12. for or incident to acupuncture, except as may
   facility primarily for rest, Custodial, Mainte-
                                                                          be provided under Acupuncture Benefits;
   nance, Domiciliary Care, or Residential Care
   except as provided under Hospice Program                           13. for or incident to Speech Therapy, speech cor-
   Benefits (see Hospice Program Benefits for                             rection or speech pathology or speech abnor-
   exception);                                                            malities that are not likely the result of a diag-
                                                                          nosed, identifiable medical condition, injury or
4. performed in a Hospital by house officers,
                                                                          illness except as specifically listed under Home
   residents, interns, and others in training;
                                                                          Health Care Benefits, Speech Therapy Benefits
5. performed by a Close Relative or by a person                           and Hospice Program Benefits;
   who ordinarily resides in the covered Mem-
                                                                      14. for drugs and medicines which cannot be law-
   ber's home;
                                                                          fully marketed without approval of the U.S.
6. for any services relating to the diagnosis or                          Food and Drug Administration (the FDA);
   treatment of any mental or emotional illness or                        however, drugs and medicines which have re-
   disorder that is not a Mental Health Condition;                        ceived FDA approval for marketing for one or
7. for any services whatsoever relating to the di-                        more uses will not be denied on the basis that
   agnosis or treatment of any Substance Abuse                            they are being prescribed for an off-label use if
   Condition, unless your Employer has pur-                               the conditions set forth in California Health
   chased substance abuse coverage as an op-                              and Safety Code, Section 1367.21 have been
   tional Benefit, in which case an accompanying                          met;



                                                                 46
15. for or incident to vocational, educational, rec-             tion of the Temporomandibular Joint and/or
    reational, art, dance, music or reading therapy;             muscles of mastication, except as specifically
    weight control programs; exercise programs;                  provided under Medical Treatment of Teeth,
    or nutritional counseling except as specifically             Gums, Jaw Joints or Jaw Bones Benefits and
    provided for under Diabetes Care Benefits;                   Hospital Benefits (Facility Services);
16. for transgender or gender dysphoria condi-                24. for or incident to services and supplies for
    tions, including but not limited to, intersex                 treatment of the teeth and gums (except for
    surgery (transsexual operations), or any related              tumors and dental and orthodontic services that
    services, or any resulting medical complica-                  are an integral part of Reconstructive Surgery
    tions, except for treatment of medical compli-                for cleft palate procedures) and associated
    cations that is Medically Necessary;                          periodontal structures, including but not lim-
                                                                  ited to diagnostic, preventive, orthodontic and
17. for sexual dysfunctions and sexual inadequa-
                                                                  other services such as dental cleaning, tooth
    cies, except as provided for treatment of or-
                                                                  whitening, X-rays, topical fluoride treatment
    ganically based conditions;
                                                                  except when used with radiation therapy to the
18. for or incident to the treatment of Infertility,              oral cavity, fillings, and root canal treatment;
    including the cause of Infertility, or any form               treatment of periodontal disease or periodontal
    of assisted reproductive technology, including                surgery for inflammatory conditions; tooth ex-
    but not limited to reversal of surgical steriliza-            traction; dental implants, braces, crowns, den-
    tion, or any resulting complications, except for              tal orthoses and prostheses; except as specifi-
    Medically Necessary treatment of medical                      cally provided under Medical Treatment of
    complications, except as specifically listed;                 Teeth, Gums, Jaw Joints or Jaw Bones Bene-
19. for callus, corn paring or excision and toenail               fits and Hospital Benefits (Facility Services);
    trimming except as may be provided through a              25. incident to organ transplant, except as explic-
    Participating Hospice Agency; treatment (other                itly listed under Transplant Benefits;
    than surgery) of chronic conditions of the foot,
                                                              26. for Cosmetic Surgery or any resulting compli-
    e.g., weak or fallen arches; flat or pronated
                                                                  cations, except that Benefits are provided for
    foot; pain or cramp of the foot; for special
                                                                  Medically Necessary Services to treat compli-
    footwear required for foot disfigurement (e.g.,
                                                                  cations of cosmetic surgery (e.g., infections or
    non-custom made or over-the-counter shoe in-
                                                                  hemorrhages), when reviewed and approved
    serts or arch supports), except as specifically
                                                                  by a Claims Administrator consultant. With-
    listed under Orthotics Benefits and Diabetes
                                                                  out limiting the foregoing, no benefits will be
    Care Benefits; bunions; or muscle trauma due
                                                                  provided for the following surgeries or proce-
    to exertion; or any type of massage procedure
                                                                  dures:
    on the foot;
                                                                     Lower eyelid blepharoplasty;
20. which are Experimental or Investigational in
    nature, except for Services for Members who                      Spider veins;
    have been accepted into an approved clinical                     Services and procedures to smooth the
    trial for cancer as provided under Clinical Trial                skin (e.g., chemical face peels, laser resur-
    for Cancer Benefits;                                             facing, and abrasive procedures);
21. for learning disabilities or behavioral problems                 Hair removal by electrolysis or other
    or social skills training/therapy;                               means; and
22. for hospitalization primarily for X-ray, labora-                 Reimplantation of breast implants origi-
    tory or any other diagnostic studies or medical                  nally provided for cosmetic augmentation;
    observation;
                                                              27. for Reconstructive Surgery and procedures
23. for dental care or services incident to the treat-            where there is another more appropriate cov-
    ment, prevention, or relief of pain or dysfunc-

                                                         47
   ered surgical procedure, or when the surgery or              Benefits, and except as provided through a
   procedure offers only a minimal improvement                  Participating Hospice Agency;
   in the appearance of the enrollee (e.g., spider           33. for prescription and non-prescription food and
   veins). In addition, no benefits will be pro-                 nutritional supplements, except as provided
   vided for the following surgeries or procedures               under Home Infusion/Home Injectable Ther-
   unless for Reconstructive Surgery:                            apy Benefits and PKU Related Formulas and
   •   Surgery to excise, enlarge, reduce, or                    Special Food Products Benefits, and except as
       change the appearance of any part of the                  provided through a Participating Hospice
       body.                                                     Agency;
   •   Surgery to reform or reshape skin or bone.            34. for home testing devices and monitoring
                                                                 equipment except as specifically provided un-
   •   Surgery to excise or reduce skin or connec-               der Durable Medical Equipment Benefits;
       tive tissue that is loose, wrinkled, sagging,
       or excessive on any part of the body.                 35. for contraceptives, except as specifically in-
                                                                 cluded in Family Planning Benefits and under
   •   Hair transplantation.                                     the Outpatient Prescription Drugs Benefits;
   •   Upper eyelid blepharoplasty without                       oral contraceptives and diaphragms are ex-
       documented significant visual impairment                  cluded, except as may be provided under the
       or symptomatology.                                        Outpatient Prescription Drugs Benefits; no
                                                                 benefits are provided for contraceptive im-
   This limitation shall not apply to breast recon-              plants;
   struction when performed subsequent to a mas-
   tectomy, including surgery on either breast to            36. for genetic testing except as described under
   achieve or restore symmetry;                                  Outpatient X-ray, Pathology and Laboratory
                                                                 Benefits;
28. for penile implant devices and surgery, and
    any related services, except for any resulting           37. for non-prescription (over-the-counter) medi-
    complications and Medically Necessary Ser-                   cal equipment or supplies that can be pur-
    vices;                                                       chased without a licensed provider's prescrip-
                                                                 tion order, even if a licensed provider writes a
29. for patient convenience items such as tele-                  prescription order for a non-prescription item,
    phone, television, guest trays, and personal hy-             except as specifically provided under Home
    giene items;                                                 Health Care Benefits, Home Infusion/Home
30. for which the Member is not legally obligated                Injectable Therapy Benefits, Hospice Program
    to pay, or for services for which no charge is               Benefits, Diabetes Care Benefits, Durable
    made;                                                        Medical Equipment Benefits, and Prosthetic
                                                                 Appliances Benefits;
31. incident to any injury or disease arising out of,
    or in the course of, any employment for salary,          38. for any services related to assisted reproductive
    wage or profit if such injury or disease is cov-             technology, including but not limited to the
    ered by any worker's compensation law, occu-                 harvesting or stimulation of the human ovum,
    pational disease law or similar legislation.                 in vitro fertilization, Gamete Intrafallopian
    However, if the Claims Administrator provides                Transfer (GIFT) procedure, artificial insemina-
    payment for such services, it will be entitled to            tion (including related medications, laboratory,
    establish a lien upon such other benefits up to              and radiology services), services or medica-
    the amount paid by the Claims Administrator                  tions to treat low sperm count, or services inci-
    for the treatment of such injury or disease;                 dent to or resulting from procedures for a sur-
                                                                 rogate mother who is otherwise not eligible for
32. in connection with private duty nursing, except
                                                                 covered Pregnancy and Maternity Care under a
    as provided under Home Health Care Benefits,
                                                                 Claims Administrator health plan;
    Home Infusion/Home Injectable Therapy

                                                        48
39. for services provided by an individual or entity         2. Your Claims Administrator group plan will
    that is not licensed or certified by the state to           provide benefits after Medicare in the follow-
    provide health care services, or is not operating           ing situations:
    within the scope of such license or certifica-              a. When you are eligible for Medicare due to
    tion, except as specifically stated herein;                    age, if the Participant is actively working
40. not specifically listed as a Benefit.                          for a group that employs less than 20 em-
                                                                   ployees (as defined by Medicare Secon-
MEDICAL NECESSITY EXCLUSION                                        dary Payer laws).
The Benefits of this Plan are intended only for                 b. When you are eligible for Medicare due to
Services that are Medically Necessary. Because a                   disability, if the Participant is covered by a
Physician or other provider may prescribe, order,                  group that employs less than 100 employ-
recommend, or approve a service or supply does                     ees (as defined by Medicare Secondary
not, in itself, make it Medically Necessary even                   Payer laws).
though it is not specifically listed as an exclusion
or limitation. The Claims Administrator reserves                c. When you are eligible for Medicare solely
the right to review all claims to determine if a ser-              due to end stage renal disease after the first
vice or supply is Medically Necessary. The                         30 months that you are eligible to receive
Claims Administrator may use the services of                       benefits for end-stage renal disease from
Doctor of Medicine consultants, peer review                        Medicare.
committees of professional societies or Hospitals               d. When you are retired and age 65 years or
and other consultants to evaluate claims. The                      older.
Claims Administrator may limit or exclude bene-
                                                                When your Claims Administrator group plan
fits for services which are not necessary.
                                                                provides benefits after Medicare, the combined
LIMITATIONS FOR DUPLICATE COVERAGE                              benefits from Medicare and your Claims Ad-
                                                                ministrator group plan may be lower but will
When you are eligible for Medicare                              not exceed the Medicare allowed amount.
1. Your Claims Administrator group plan will                    Your Claims Administrator group plan De-
   provide benefits before Medicare in the fol-                 ductible and Copayments will be waived.
   lowing situations:                                        When you are eligible for Medi-Cal
    a. When you are eligible for Medicare due to             Medi-Cal always provides benefits last.
       age, if the Participant is actively working
       for a group that employs 20 or more em-               When you are a qualified veteran
       ployees (as defined by Medicare Secon-                If you are a qualified veteran your Claims Admin-
       dary Payer laws).                                     istrator group plan will pay the reasonable value or
    b. When you are eligible for Medicare due to             the Claims Administrator’s Allowable Amount for
       disability, if the Participant is covered by a        covered services provided to you at a Veterans
       group that employs 100 or more employees              Administration facility for a condition that is not
       (as defined by Medicare Secondary Payer               related to military service. If you are a qualified
       laws).                                                veteran who is not on active duty, your Claims
                                                             Administrator group plan will pay the reasonable
    c. When you are eligible for Medicare solely             value or the Claims Administrator’s Allowable
       due to end stage renal disease during the             Amount for covered services provided to you at a
       first 30 months that you are eligible to re-          Department of Defense facility, even if provided
       ceive benefits for end-stage renal disease            for conditions related to military service.
       from Medicare.




                                                        49
When you are covered by another government                      brought against the third party arising from the
agency                                                          alleged acts or omissions causing the injury or
                                                                illness, not later than 30 days after submitting
If you are also entitled to benefits under any other
                                                                or filing a claim or legal action against the
federal or state governmental agency, or by any
                                                                third party; and
municipality, county or other political subdivision,
the combined benefits from that coverage and your           2. Agree to fully cooperate with the Plan Admin-
Claims Administrator group plan will equal, but                istrator to execute any forms or documents
not exceed, what the Claims Administrator would                needed to assist the Plan in exercising their eq-
have paid if you were not eligible to receive bene-            uitable right to restitution or other available
fits under that coverage (based on the reasonable              remedies; and
value or the Claims Administrator’s Allowable               3. Provide the Plan Administrator with a lien, in
Amount).                                                       the amount of reasonable costs of benefits pro-
Contact the Customer Service department at the                 vided, calculated in accordance with California
telephone number shown at the end of this docu-                Civil Code section 3040. The lien may be
ment if you have any questions about how the                   filed with the third party, the third party's agent
Claims Administrator coordinates your group plan               or attorney, or the court, unless otherwise pro-
benefits in the above situations.                              hibited by law.

EXCEPTION FOR OTHER COVERAGE                                A Member’s failure to comply with 1. through 3.
                                                            above shall not in any way act as a waiver, release,
Participating Providers and Preferred Providers             or relinquishment of the rights of the Plan Admin-
may seek reimbursement from other third party               istrator.
payers for the balance of their reasonable charges
for Services rendered under this Plan.                      Further, if the Member receives Services from a
                                                            Participating Hospital for such injuries, the Hospi-
CLAIMS REVIEW                                               tal has the right to collect from the Member the
                                                            difference between the amount paid by the Claims
The Claims Administrator reserves the right to re-          Administrator and the Hospital’s reasonable and
view all claims to determine if any exclusions or           necessary charges for such Services when payment
other limitations apply. The Claims Administrator           or reimbursement is received by the Member for
may use the services of Physician consultants, peer         medical expenses. The Participating Hospital’s
review committees of professional societies or              right to collect shall be in accordance with Cali-
Hospitals, and other consultants to evaluate claims.        fornia Civil Code Section 3045.1.

REDUCTIONS – THIRD PARTY LIABILITY                          IF THIS PLAN IS PART OF AN EMPLOYEE
                                                            WELFARE BENEFIT PLAN SUBJECT TO
If a Member is injured through the act or omission          THE EMPLOYEE RETIREMENT INCOME
of another person (a “third party”), the Claims             SECURITY ACT OF 1974 (“ERISA”), THE
Administrator shall, with respect to Services re-           FOLLOWING THIRD PARTY LIABILITY
quired as a result of that injury, provide the Bene-        SECTION APPLIES
fits of the Plan and the Plan Administrator have an
equitable right to restitution or other available           If a Member’s injury or illness was, in any way,
remedy to recover the reasonable costs of the Ser-          caused by a third party who may be legally liable
vices provided to the Member paid on a fee-for-             or responsible for the injury or illness, no benefits
service basis.                                              will be payable or paid under the Plan unless the
                                                            Member agrees in writing, in a form satisfactory to
The Member is required to:
                                                            the Plan, to do all of the following:
1. Notify the Plan Administrator in writing of any
   actual or potential claim or legal action which          1. Provide the Plan with a written notice of any
   such Member anticipates bringing or has                     claim made against the third party for damages
                                                               as a result of the injury or illness;

                                                       50
2. Agree in writing to reimburse the Plan for                 of how held, and includes monies directly received
   benefits paid by the Plan from any Recovery                as well as any monies held in any account or trust
   (defined below) when the Recovery is obtained              on behalf of the Member, such as an attorney-
   from or on behalf of the third party or the in-            client trust account.
   surer of the third party, or from the Member’s
   own uninsured or underinsured motorist cover-              The Member shall pay to the Plan from the Recov-
   age;                                                       ery an amount equal to the benefits actually paid
                                                              by the Plan in connection with the illness or injury.
3. Execute a lien in favor of the Plan for the full           If the benefits paid by the Plan in connection with
   amount of benefits paid by the Plan;                       the illness or injury exceed the amount of the Re-
                                                              covery, the Member shall not be responsible to
4. Ensure that any Recovery is kept separate from             reimburse the Plan for the benefits paid in connec-
   and not comingled with any other funds and                 tion with the illness or injury in excess of the Re-
   agree in writing that the portion of any Recov-            covery.
   ery required to satisfy the lien of the Plan is
   held in trust for the sole benefit of the Plan un-         The Member’s acceptance of benefits from the
   til such time it is conveyed to the Plan;                  Plan for illness or injury caused by a third party
                                                              shall act as a waiver of any defense to full reim-
5. Periodically respond to information requests               bursement of the Plan from the Recovery, includ-
   regarding the claim against the third party, and           ing any defense that the injured individual has not
   notify the Plan, in writing, within ten (10) days          been “made whole” by the Recovery or that the
   after any Recovery has been obtained;                      individual’s attorneys fees and costs, in whole or
6. Direct any legal counsel retained by the Mem-              in part, are required to be paid or are payable from
   ber or any other person acting on behalf of the            the Recovery, or that the Plan should pay a portion
   Member to hold that portion of the Recovery                of the attorneys fees and costs incurred in connec-
   to which the Plan is entitled in trust for the sole        tion with the claims against the third party.
   benefit of the Plan and to comply with and fa-             TERMINATION OF BENEFITS AND
   cilitate the reimbursement to the Plan of the
   monies owed it.                                            CANCELLATION PROVISIONS
If a Member fails to comply with the above re-                TERMINATION OF BENEFITS
quirements, no benefits will be paid with respect to          Except as specifically provided under the Extension of Bene-
the injury or illness. If benefits have been paid,            fits provision, and, if applicable, the Continuation of Group
                                                              Coverage provision, there is no right to receive benefits for
they may be recouped by the Plan, through deduc-              services provided following termination of this Plan.
tions from future benefit payments to the Member
or others enrolled through the Member in the Plan.            Coverage for you or your Dependents terminates at 12:01
                                                              a.m. Pacific Time on the earliest of these dates: (1) the date
“Recovery” includes any amount awarded to or                  the Plan is discontinued, (2) the first day of the month fol-
                                                              lowing the month in which the Participant’s employment
received by way of court judgment, arbitration                terminates, unless a different date has been agreed to between
award, settlement or any other arrangement, from              the Claims Administrator and your Employer, (3) fifteen (15)
any third party or third party insurer, or from your          days following the date of mailing of the notice to the Em-
uninsured or underinsured motorist coverage, re-              ployer that fees are not paid, or (4) on the first day of the
lated to the illness or injury, without reduction for         month following the month in which you or your Dependents
                                                              become ineligible. A spouse also becomes ineligible follow-
any attorneys’ fees paid or owed by the Member or             ing legal separation from the Participant, entry of a final de-
on the Member’s behalf, and without regard to                 cree of divorce, annulment or dissolution of marriage from
whether the Member has been “made whole” by                   the Participant. A Domestic Partner becomes ineligible upon
the Recovery. Recovery does not include monies                termination of the domestic partnership.
received from any insurance policy or certificate             If you cease work because of retirement, disability, leave of
issued in the name of the Member, except for un-              absence, temporary layoff, or termination, see your Employer
insured or underinsured motorist coverage. The                about possibly continuing group coverage. Also see the In-
Recovery includes all monies received, regardless             dividual Conversion Plan provision, and, if applicable, the


                                                         51
Continuation of Group Coverage provision in this booklet for            such reasonable intervals as determined by the Claims Ad-
information on continuation of coverage.                                ministrator.
If your Employer is subject to the federal Family and Medi-
cal Leave Act of 1993, and the approved leave of absence is             COORDINATION OF BENEFITS
for family leave under the terms of such Act(s), your pay-              Coordination of Benefits is designed to provide maximum
ment of fees will keep your coverage in force for such period           coverage for medical and Hospital Services at the lowest cost
of time as specified in such Act(s). Your Employer is solely            by avoiding excessive payments.
responsible for notifying you of the availability and duration
of family leaves.                                                       When a Member who is covered under this group Plan is also
                                                                        covered under another group plan, or selected group, or blan-
The Claims Administrator may terminate your and your De-                ket disability insurance contract, or any other contractual
pendent’s coverage for cause immediately upon written no-               arrangement or any portion of any such arrangement
tice to you and your Employer for the following:                        whereby the members of a group are entitled to payment of
1.   Material information that is false, or misrepresented              or reimbursement for Hospital or medical expenses, such
     information provided on the enrollment application or              Member will not be permitted to make a “profit” on a disabil-
     given to your Employer or the Claims Administrator;                ity by collecting benefits in excess of actual value or cost
                                                                        during any Calendar Year.
2.   Permitting use of your Participant identification card
     by someone other than yourself or your Dependents to               Instead, payments will be coordinated between the plans in
     obtain Services;                                                   order to provide for “allowable expenses” (these are the ex-
                                                                        penses that are Incurred for services and supplies covered
3.   Obtaining or attempting to obtain Services under the               under at least one of the plans involved) up to the maximum
     Plan by means of false, materially misleading, or                  benefit value or amount payable by each plan separately.
     fraudulent information, acts or omissions;
                                                                        If the covered Member is also entitled to benefits under any
4.   Abusive or disruptive behavior which: (1) threatens the            of the conditions as outlined under the “Limitations for Du-
     life or well-being of Claims Administrator personnel               plicate Coverage” provision, benefits received under any
     and providers of Services, or, (2) substantially impairs           such condition will not be coordinated with the Benefits of
     the ability of the Claims Administrator to arrange for             this Plan.
     services to the Participant, or, (3) substantially impairs
     the ability of providers of Service to furnish Services to         The following rules determine the order of benefit payments:
     the Participant or to other patients.                              When the other plan does not have a coordination of benefits
If a written application for the addition of a newborn or a             provision it will always provide its benefits first. Otherwise,
child placed for adoption is not submitted to and received by           the plan covering the Member as an employee will provide
the Claims Administrator within the 31 days following that              its benefits before the plan covering the Member as a De-
Dependent's effective date of coverage, Benefits under this             pendent.
Plan will be terminated on the 32nd day at 12:01 a.m. Pacific           Except for cases of claims for a Dependent child whose par-
Time.                                                                   ents are separated or divorced, the plan which covers the
                                                                        Dependent child of a Member whose date of birth, (exclud-
EXTENSION OF BENEFITS                                                   ing year of birth), occurs earlier in a Calendar Year, shall
If a Participant becomes Totally Disabled while validly cov-            determine its benefits before a plan which covers the De-
ered under this Plan and continues to be Totally Disabled on            pendent child of a Member whose date of birth, (excluding
the date the Plan terminates, the Claims Administrator will             year of birth), occurs later in a Calendar Year. If either plan
extend the Benefits of this Plan, subject to all limitations and        does not have the provisions of this paragraph regarding De-
restrictions, for covered Services and supplies directly related        pendents, which results either in each plan determining its
to the condition, illness or injury causing such Total Disabil-         benefits before the other or in each plan determining its bene-
ity until the first to occur of the following: (1) 12:01 a.m. on        fits after the other, the provisions of this paragraph shall not
the day following a period of twelve months from the date               apply, and the rule set forth in the plan which does not have
coverage terminated; (2) the date the Participant is no longer          the provisions of this paragraph shall determine the order of
Totally Disabled; (3) the date on which the Participant's               benefits.
maximum Benefits are reached; (4) the date on which a re-               1.   In the case of a claim involving expenses for a Depend-
placement carrier provides coverage to the Participant that is               ent child whose parents are separated or divorced, plans
not subject to a pre-existing condition exclusion. The time                  covering the child as a Dependent will determine their
the Participant was covered under this Plan will apply toward                respective benefits in the following order:
the replacement plan’s pre-existing condition exclusion.
                                                                             First, the plan of the parent with custody of the child;
No extension will be granted unless the Claims Administrator                 then, if that parent has remarried, the plan of the steppar-
receives written certification of such Total Disability from a               ent with custody of the child; and finally the plan(s) of
licensed Doctor of Medicine (M.D.) within 90 days of the                     the parent(s) without custody of the child.
date on which coverage was terminated, and thereafter at

                                                                   52
2.   Notwithstanding (1.) above, if there is a court decree             these provisions or any provisions of similar purpose of any
     which otherwise establishes financial responsibility for           other plan. Any person claiming Benefits under this Plan
     the medical, dental or other health care expenses of the           shall furnish the Claims Administrator with such information
     child, then the plan which covers the child as a Depend-           as may be necessary to implement these provisions.
     ent of the parent with that financial responsibility shall
     determine its benefits before any other plan which cov-            GROUP CONTINUATION COVERAGE AND
     ers the child as a Dependent child.                                INDIVIDUAL CONVERSION PLAN
3.   If the above rules do not apply, the plan which has cov-
     ered the patient for the longer period of time shall de-           CONTINUATION OF GROUP COVERAGE
     termine its benefits first, provided that:
                                                                        Please examine your options carefully before declining this
     a.   a plan covering a patient as a laid-off or retired em-        coverage. You should be aware that companies selling indi-
          ployee, or as a Dependent of such an employee,                vidual health insurance typically require a review of your
          shall determine its benefits after any other plan cov-        medical history that could result in a higher premium or you
          ering that Member as an employee, other than a                could be denied coverage entirely.
          laid-off or retired employee, or such Dependent;
                                                                        Applicable to Members when the Participant’s Employer is
          and
                                                                        subject to either Title X of the Consolidated Omnibus Budget
     b.   if either plan does not have a provision regarding            Reconciliation Act (COBRA) as amended.
          laid-off or retired employees, which results in each
                                                                        In accordance with the Consolidated Omnibus Budget Rec-
          plan determining its benefits after the other, then
                                                                        onciliation Act (COBRA) as amended, a Member will be
          provisions of (a.) above shall not apply.
                                                                        entitled to elect to continue group coverage under this Plan if
If this Plan is the primary carrier with respect to a covered           the Member would otherwise lose coverage because of a
person, then this Plan will provide its Benefits without reduc-         Qualifying Event that occurs while the Employer is subject to
tion because of benefits available from any other plan.                 the continuation of group coverage provisions of COBRA.
When this Plan is secondary in the order of payments, and               The benefits under the group continuation of coverage will
the Claims Administrator is notified that there is a dispute as         be identical to the benefits that would be provided to the
to which plan is primary, or that the primary plan has not              Member if the Qualifying Event had not occurred (including
paid within a reasonable period of time, this Plan will provide         any changes in such coverage).
the Benefits that would be due as if it were the primary plan,
                                                                        Note: Under COBRA, a Member is entitled to benefits if at
provided that the covered Member (1) assigns to the Claims
                                                                        the time of the qualifying event such Member is entitled to
Administrator the right to receive benefits from the other plan
                                                                        Medicare or has coverage under another group health plan.
to the extent of the difference between the value of the Bene-
                                                                        However, if Medicare entitlement or coverage under another
fits which the Claims Administrator actually provides and the
                                                                        group health plan arises after COBRA coverage begins, it
value of the Benefits that the Claims Administrator would
                                                                        will cease.
have been obligated to provide as the secondary plan, (2)
agrees to cooperate fully with the Claims Administrator in              Qualifying Event
obtaining payment of benefits from the other plan, and (3)
allows the Claims Administrator to obtain confirmation from             A Qualifying Event is defined as a loss of coverage as a re-
the other plan that the benefits which are claimed have not             sult of any one of the following occurrences.
previously been paid.                                                   1.   With respect to the Participant:
If payments which should have been made under this Plan in                   a.   the termination of employment (other than by rea-
accordance with these provisions have been made by another                        son of gross misconduct); or
plan, the Claims Administrator may pay to the other plan the
amount necessary to satisfy the intent of these provisions.                  b.   the reduction of hours of employment to less than
This amount shall be considered as Benefits paid under this                       the number of hours required for eligibility.
Plan. The Claims Administrator shall be fully discharged                2.   With respect to the Dependent spouse or Dependent
from liability under this Plan to the extent of these payments.              Domestic Partner* and Dependent children (children
If payments have been made by the Claims Administrator in                    born to or placed for adoption with the Participant or
excess of the maximum amount of payment necessary to                         Domestic Partner during a COBRA continuation period
satisfy these provisions, the Claims Administrator shall have                may be immediately added as Dependents, provided the
the right to recover the excess from any person or other entity              Planholder is properly notified of the birth or placement
to or with respect to whom such payments were made.                          for adoption, and such children are enrolled within 30
                                                                             days of the birth or placement for adoption):
The Claims Administrator may release to or obtain from any
organization or person any information which the Claims                      *Note: Domestic Partners and Dependent children of
Administrator considers necessary for the purpose of deter-                  Domestic Partners cannot elect COBRA on their own,
mining the applicability of and implementing the terms of


                                                                   53
     and are only eligible for COBRA if the Participant elects            Duration and Extension
     to enroll.                                                           of Continuation of Group Coverage
     a.   the death of the Participant; or                                In no event will continuation of group coverage under CO-
                                                                          BRA be extended for more than 3 years from the date the
     b.   the termination of the Participant’s employment
                                                                          Qualifying Event has occurred which originally entitled the
          (other than by reason of such Participant’s gross
                                                                          Member to continue group coverage under this Plan.
          misconduct); or
                                                                          Note: Domestic Partners and Dependent children of Domes-
     c.   the reduction of the Participant’s hours of employ-
                                                                          tic Partners cannot elect COBRA on their own, and are only
          ment to less than the number of hours required for
                                                                          eligible for COBRA if the Participant elects to enroll.
          eligibility; or
     d.   the divorce or legal separation of the Participant              Payment of Dues
          from the Dependent spouse or termination of the                 Dues for the Member continuing coverage shall be 102 per-
          domestic partnership; or                                        cent of the applicable group dues rate, except for the Member
     e.   the Participant’s entitlement to benefits under Title           who is eligible to continue group coverage to 29 months be-
          XVIII of the Social Security Act (“Medicare”); or               cause of a Social Security disability determination, in which
                                                                          case, the dues for months 19 through 29 shall be 150 percent
     f.   a Dependent child’s loss of Dependent status under              of the applicable group dues rate.
          this Plan.
                                                                          If the Member is enrolled in COBRA and is contributing to
3.   With respect to a Participant who is covered as a retiree,           the cost of coverage, the Employer shall be responsible for
     that retiree’s Dependent spouse and Dependent children,              collecting and submitting all dues contributions to the Claims
     the Employer's filing for reorganization under Title XI,             Administrator in the manner and for the period established
     United States Code, commencing on or after July 1,                   under this Plan.
     1986.
                                                                          Effective Date
4.   With respect to any of the above, such other Qualifying              of the Continuation of Coverage
     Event as may be added to Title X of COBRA.
                                                                          The continuation of coverage will begin on the date the
Notification of a Qualifying Event                                        Member's coverage under this Plan would otherwise termi-
The Member is responsible for notifying the Employer of                   nate due to the occurrence of a Qualifying Event and it will
divorce, legal separation, or a child's loss of Dependent status          continue for up to the applicable period, provided that cover-
under this Plan, within 60 days of the date of the later of the           age is timely elected and so long as dues are timely paid.
Qualifying Event or the date on which coverage would oth-                 Termination
erwise terminate under this Plan because of a Qualifying                  of Continuation of Group Coverage
Event.
                                                                          The continuation of group coverage will cease if any one of
The Employer is responsible for notifying its COBRA ad-                   the following events occurs prior to the expiration of the ap-
ministrator (or Plan administrator if the Employer does not               plicable period of continuation of group coverage:
have a COBRA administrator) of the Participant's death, ter-
mination, or reduction of hours of employment, the Partici-               1.   discontinuance of this Plan (if the Employer continues to
pant's Medicare entitlement or the Employer's filing for reor-                 provide any group benefit plan for Employees, the
ganization under Title XI, United States Code.                                 Member may be able to continue coverage with another
                                                                               plan);
When the COBRA administrator is notified that a Qualifying
Event has occurred, the COBRA administrator will, within                  2.   failure to timely and fully pay the amount of required
14 days, provide written notice to the Member by first class                   dues to the COBRA administrator or the Employer or to
mail of the Member’s right to continue group coverage under                    the Claims Administrator as applicable. Coverage will
this Plan. The Member must then notify the COBRA admin-                        end as of the end of the period for which dues were paid;
istrator within 60 days of the later of (1) the date of the notice        3.   the Member becomes covered under another group
of the Member’s right to continue group coverage and (2) the                   health plan that does not include a pre-existing condition
date coverage terminates due to the Qualifying Event.                          exclusion or limitation provision that applies to the
If the Member does not notify the COBRA administrator                          Member;
within 60 days, the Member’s coverage will terminate on the               4.   the Member becomes entitled to Medicare;
date the Member would have lost coverage because of the
Qualifying Event.                                                         5.   the Member no longer resides in the Claims Administra-
                                                                               tor’s service area;
                                                                          6.   the Member commits fraud or deception in the use of the
                                                                               Services of this Plan.


                                                                     54
Continuation of group coverage in accordance with COBRA                     rangement of coverage for individuals in a group,
will not be terminated except as described in this provision.               whether insured or self-insured; and,
                                                                       6.   You are covered for similar benefits under an individual
Continuation of Group Coverage                                              policy or contract.
for Members on Military Leave                                          Benefits or rates of an individual conversion health plan are
Continuation of group coverage is available for Members on             different from those in your group Plan.
military leave if the Member’s Employer is subject to the              A conversion plan is also available to:
Uniformed Services Employment and Re-employment
Rights Act (USERRA). Members who are planning to enter                 1.   Dependents, if the Participant dies;
the Armed Forces should contact their Employer for informa-            2.   Dependents who marry or exceed the maximum age for
tion about their rights under the USERRA. Employers are                     Dependent coverage under the group Plan;
responsible to ensure compliance with this act and other state
and federal laws regarding leaves of absence including the             3.   Dependents, if the Participant enters military service;
California Family Rights Act, the Family and Medical Leave             4.   Spouse or Domestic Partner of a Participant if their mar-
Act, and Labor Code requirements for Medical Disability.                    riage or domestic partnership has been terminated;

AVAILABILITY OF THE CLAIMS ADMINISTRATOR                               5.   Dependents, when continuation of coverage under CO-
                                                                            BRA expires, or is terminated.
INDIVIDUAL PLANS
                                                                       When a Dependent reaches the limiting age for coverage as a
The Claims Administrator's Individual Plans described below
                                                                       Dependent, or if a Dependent becomes ineligible for any of
may be available to Members whose group coverage or                    the other reasons given above, it is your responsibility to in-
COBRA coverage is terminated or expires while covered                  form the Claims Administrator. Upon receiving notification,
under this group Plan.
                                                                       the Claims Administrator will offer such Dependent an indi-
                                                                       vidual conversion plan for purposes of continuous coverage.
INDIVIDUAL CONVERSION PLAN
                                                                       Guaranteed Issue Individual Coverage
Continued Protection
                                                                       Under the Health Insurance Portability and Accountability
Regardless of age, physical condition, or employment status,           Act of 1996 (HIPAA), you may be entitled to apply for cer-
you may continue the Claims Administrator protection when              tain of the Claims Administrator’s individual health plans on
you retire, leave the job, or become ineligible for group cov-         a guaranteed issue basis (which means that you will not be
erage. If you have held group coverage for three or more               rejected for underwriting reasons if you meet the other eligi-
consecutive months, you and your enrolled Dependents may               bility requirements, you live or work in the Claims Adminis-
apply to transfer to an individual conversion plan then being          trator’s service area and you agree to pay all required Dues).
issued by the Claims Administrator.                                    You may also be eligible to purchase similar coverage on a
Your Employer is solely responsible for notifying you of the           guaranteed issue basis from any other health plan that sells
availability, terms, and conditions of the individual conver-          individual coverage for hospital, medical or surgical benefits.
sion plan within 15 days of termination of the Plan.                   Not all Claims Administrator individual plans are available
                                                                       on a guaranteed issue basis under HIPAA. To be eligible,
An application and first Dues payment for the individual               you must meet the following requirements:
conversion plan must be received by the Claims Administra-
tor within 63 days of the date of termination of your group            •    You must have at least 18 or more months of creditable
coverage. However, if the Plan is replaced by your Employer                 coverage.
with similar coverage under another contract within 15 days,           •    Your most recent coverage must have been group cover-
transfer to the individual conversion health plan will not be               age (COBRA is considered group coverage for these
permitted. You will not be permitted to transfer to the indi-               purposes).
vidual conversion plan under any of the following circum-
stances:                                                               •    You must have elected and exhausted all COBRA cov-
                                                                            erage that is available to you.
1.   You failed to pay amounts due the Plan;
                                                                       •    You must not be eligible for nor have any other health
2.   You were terminated by the Plan for good cause or for
                                                                            insurance coverage, including a group health plan,
     fraud or misrepresentation;
                                                                            Medicare or Medi-Cal.
3.   You knowingly furnished incorrect information or oth-
                                                                       •    You must make application to the Claims Administrator
     erwise improperly obtained the Benefits of the Plan;
                                                                            for guaranteed issue coverage within 63 days of the date
4.   You are covered or eligible for Medicare;                              of termination from the group plan.
5.   You are covered or eligible for Hospital, medical or sur-         If you elect Conversion Coverage or other Claims Adminis-
     gical benefits under state or federal law or under any ar-        trator individual plans, you will waive your right to this guar-

                                                                  55
anteed issue coverage. For more information, contact a                  PLAN INTERPRETATION
Claims Administrator Customer Service representative at the
telephone number noted on your ID Card.                                 The Claims Administrator shall have the power and discre-
                                                                        tionary authority to construe and interpret the provisions of
GENERAL PROVISIONS                                                      this Plan, to determine the Benefits of this Plan and deter-
                                                                        mine eligibility to receive Benefits under this Plan. The
LIABILITY OF PARTICIPANTS IN THE EVENT OF                               Claims Administrator shall exercise this authority for the
                                                                        Benefits of all Members entitled to receive Benefits under
NON-PAYMENT BY THE CLAIMS ADMINISTRATOR
                                                                        this Plan.
In accordance with the Claims Administrator's es-
tablished policies, and by statute, every contract                      CONFIDENTIALITY OF PERSONAL AND HEALTH
between the Claims Administrator and its Partici-                       INFORMATION
pating Providers and Preferred Providers stipulates                     The Claims Administrator protects the confidential-
that the Participant shall not be responsible to the                    ity/privacy of your personal and health information. Personal
Participating Provider or Preferred Provider for                        and health information includes both medical information
compensation for any Services to the extent that                        and individually identifiable information, such as your name,
                                                                        address, telephone number, or social security number. The
they are provided in the Participant's Plan. Partici-                   Claims Administrator will not disclose this information with-
pating Providers and Preferred Providers have                           out your authorization, except as permitted by law.
agreed to accept the Plan’s payment as payment-
                                                                        A STATEMENT DESCRIBING THE CLAIMS
in-full for covered Services, except for the De-
                                                                        ADMINISTRATOR'S POLICIES AND PROCE-
ductibles, Copayments, amounts in excess of
                                                                        DURES FOR PRESERVING THE CONFIDEN-
specified Benefit maximums, or as provided under
                                                                        TIALITY OF MEDICAL RECORDS IS AVAIL-
the Exception for Other Coverage provision and
                                                                        ABLE AND WILL BE FURNISHED TO YOU
the Reductions section regarding Third Party Li-
                                                                        UPON REQUEST.
ability.
                                                                        The Claims Administrator’s policies and procedures regard-
If Services are provided by a Non-Preferred Pro-                        ing our confidentiality/privacy practices are contained in the
vider, the Participant is responsible for all amounts                   “Notice of Privacy Practices”, which you may obtain either
the Claims Administrator does not pay.                                  by calling the Customer Service Department at the number
                                                                        listed in the back of this booklet, or by accessing the Claims
When a Benefit specifies a Benefit maximum and                          Administrator’s        Internet       site     located       at
that Benefit maximum has been reached, the Par-                         http://www.blueshieldca.com and printing a copy.
ticipant is responsible for any charges above the                       If you are concerned that the Claims Administrator may have
Benefit maximums.                                                       violated your confidentiality/privacy rights, or you disagree
                                                                        with a decision we made about access to your personal and
NON-ASSIGNABILITY                                                       health information, you may contact us at:
Coverage or any Benefits of this Plan may not be assigned               Correspondence Address:
without the written consent of the Claims Administrator.                Blue Shield of California Privacy Official
Possession of a Claims Administrator ID card confers no                 P.O. Box 272540
right to Services or other Benefits of this Plan. To be entitled        Chico, CA 95927-2540
to Services, the Member must be a Participant or Dependent
who has been accepted by the Employer and enrolled by the               Toll-Free Telephone:
Claims Administrator and who has maintained enrollment                  1-888-266-8080
under the terms of this Plan.
                                                                        Email Address:
Participating Providers and Preferred Providers are paid di-
rectly by the Claims Administrator. The Member or the pro-              blueshieldca_privacy@blueshieldca.com
vider of Service may not request that payment be made di-
rectly to any other party.                                              ACCESS TO INFORMATION
If the Member receives Services from a Non-Preferred Pro-               The Claims Administrator may need information from medi-
vider, payment will be made directly to the Participant, and            cal providers, from other carriers or other entities, or from
the Participant is responsible for payment to the Non-                  you, in order to administer benefits and eligibility provisions
Preferred Provider. The Member or the provider of Service               of this Plan. You agree that any provider or entity can dis-
may not request that the payment be made directly to the                close to the Claims Administrator that information that is
provider of Service.                                                    reasonably needed by the Claims Administrator. You agree

                                                                   56
to assist the Claims Administrator in obtaining this informa-          the processing of the claim. The Claims Administrator will
tion, if needed, (including signing any necessary authoriza-           acknowledge receipt of a written grievance within 5 calendar
tions) and to cooperate by providing the Claims Administra-            days.
tor with information in your possession. Failure to assist the
                                                                       The Claims Administrator reserves the right to refer appro-
Claims Administrator in obtaining necessary information or
                                                                       priate matters to a Peer Review committee of the appropriate
refusal to provide information reasonably needed may result
                                                                       local medical or dental society or of the California Medical
in the delay or denial of benefits until the necessary informa-
                                                                       or Dental Association which is appropriate for such review.
tion is received. Any information received for this purpose
by the Claims Administrator will be maintained as confiden-            The grievance system allows Participants to file grievances
tial and will not be disclosed without your consent, except as         for at least 180 days following any incident or action that is
otherwise permitted by law.                                            the subject of the enrollee’s dissatisfaction. Appeals are re-
                                                                       solved in writing, within 30 days of the date of receipt.
INDEPENDENT CONTRACTORS
                                                                       Final Appeal
Providers are neither agents nor employees of the Plan but
are independent contractors. In no instance shall the Plan be          If the Participant is dissatisfied with the administrative re-
liable for the negligence, wrongful acts, or omissions of any          view determination by the Claims Administrator, the deter-
person receiving or providing services, including any Physi-           mination may be appealed in writing to the Employer within
cian, Hospital, or other provider or their employees.                  60 days after notice of the administrative review determina-
                                                                       tion. Such written request shall contain any additional in-
                                                                       formation which the Participant wishes the Employer to con-
CUSTOMER SERVICE                                                       sider. The Employer shall notify the Participant in writing of
If you have a question about Services, providers, Benefits,            the results of its review and the specific basis therefore. In
how to use this Plan, or concerns regarding the quality of             the event the Employer finds all or part of the appeal to be
care or access to care that you have experienced, you may              valid, the Employer shall direct the Claims Administrator to
contact the Customer Service Department as noted on the last           reimburse the Participant for those expenses which the Em-
page of this booklet.                                                  ployer allowed as a result of its review of the appeal. The
                                                                       Employer's determination shall be final and binding on all
The hearing impaired may contact the Customer Service De-              parties.
partment through the Claims Administrator’s toll-free TTY
number, 1-800-241-1823.
                                                                       DEFINITIONS
Customer Service can answer many questions over the tele-
phone.                                                                 PLAN PROVIDER DEFINITIONS
Note: The Claims Administrator has established a procedure             Whenever any of the following terms are capitalized in this
for our Participants and Dependents to request an expedited            booklet, they will have the meaning stated below:
decision. A Member, Physician, or representative of a Mem-
ber may request an expedited decision when the routine deci-           Alternate Care Services Providers — Durable Medical
sion making process might seriously jeopardize the life or             Equipment suppliers, individual certified orthotists, prosthe-
health of a Member, or when the Member is experiencing                 tists and prosthetist-orthotists.
severe pain. The Claims Administrator shall make a decision            Doctor of Medicine — a licensed Medical Doctor (M.D.) or
and notify the Member and Physician as soon as possible to             Doctor of Osteopathic Medicine (D.O.).
accommodate the Member’s condition not to exceed 72
hours following the receipt of the request. An expedited de-           Hospice or Hospice Agency — an entity which provides
cision may involve admissions, continued stay or other                 Hospice services to Terminally Ill persons and holds a li-
healthcare Services. If you would like additional information          cense, currently in effect as a Hospice which has Medicare
regarding the expedited decision process, or if you believe            certification.
your particular situation qualifies for an expedited decision,         Hospital —
please contact our Customer Service Department at the num-
ber provided on the last page of this booklet.                         1.   a licensed institution primarily engaged in providing, for
                                                                            compensation from patients, medical, diagnostic and
                                                                            surgical facilities for care and treatment of sick and in-
SETTLEMENT OF DISPUTES                                                      jured persons on an Inpatient basis, under the supervi-
                                                                            sion of an organized medical staff, and which provides
Request for Initial Appeal
                                                                            24 hour a day nursing service by registered nurses. A
If a claim has been denied in whole or in part by the Claims                facility which is principally a rest home or nursing home
Administrator, the Participant may request the Customer                     or home for the aged is not included.
Service Department of the Claims Administrator to give fur-
                                                                       2.   a psychiatric Hospital accredited by the Joint Commis-
ther consideration to the claim, by telephone or written re-
                                                                            sion on Accreditation of Healthcare Organizations.
quest including any additional information that would affect

                                                                  57
Non-Participating Home Health Care and Home Infusion                    Participating Home Health Care and Home Infusion
Agency — an agency which has not contracted with the                    Agency — an agency which has contracted with the Claims
Claims Administrator and whose services are not covered                 Administrator to furnish services and accept reimbursement
unless prior authorized by the Claims Administrator.                    at negotiated rates, and which has been designated as a Par-
                                                                        ticipating Home Health Care and Home Infusion agency by
Non-Participating/Non-Preferred Providers — any pro-
                                                                        the Claims Administrator. (See Non-Participating Home
vider who has not contracted with the Claims Administrator
                                                                        Health Care and Home Infusion agency definition above.)
to accept the Claims Administrator 's payment, plus any ap-
plicable Deductible, Copayment, or amounts in excess of                 Participating Hospice or Participating Hospice Agency —
specified Benefit maximums, as payment-in-full for covered              an entity which: 1) provides Hospice services to Terminally
Services.                                                               Ill Members and holds a license, currently in effect, as a
                                                                        Hospice pursuant to Health and Safety Code Section 1747, or
Non-Preferred Hemophilia Infusion Provider — a pro-
                                                                        a home health agency licensed pursuant to Health and Safety
vider that has not contracted with the Claims Administrator
                                                                        Code Sections 1726 and 1747.1 which has Medicare certifi-
to furnish blood factor replacement products and services for
                                                                        cation and 2) has either contracted with the Claims Adminis-
in-home treatment of blood disorders such as hemophilia and
                                                                        trator or has received prior approval from the Claims Admin-
accept reimbursement at negotiated rates, and that has not
                                                                        istrator to provide Hospice Service Benefits pursuant to the
been designated as a contracted hemophilia infusion product
                                                                        California Health and Safety Code Section 1368.2.
provider by the Claims Administrator. Note: Non-Preferred
Hemophilia Infusion Providers may include Participating                 Participating Physician — a selected Physician who has
Home Health Care and Home Infusion Agency Providers if                  agreed to accept the Claims Administrator’s payment, plus
that provider does not also have an agreement with the                  Participant payments of any applicable Deductibles and Co-
Claims Administrator to furnish blood factor replacement                payments as payment-in-full for covered Services. Refer to
products and services.                                                  the Payment section of this booklet for Copayment informa-
                                                                        tion.
Other Providers —
                                                                        Participating Provider — a Physician, a Hospital, an Am-
1.   Independent Practitioners — licensed vocational nurses;
                                                                        bulatory Surgery Center, an Alternate Care Services Pro-
     licensed practical nurses; registered nurses; licensed
                                                                        vider, a Certified Registered Nurse Anesthetist, or a Home
     psychiatric nurses; registered dieticians; certified nurse
                                                                        Health Care and Home Infusion agency that has contracted
     midwives; licensed occupational therapists; certificated
                                                                        with the Claims Administrator to furnish Services and to
     acupuncturists;     certified    respiratory    therapists;
                                                                        accept the Claims Administrator’s payment, plus applicable
     enterostomal therapists; licensed speech therapists or
                                                                        Deductibles and Copayments, as payment in full for covered
     pathologists; dental technicians; and lab technicians.
                                                                        Services.
2.   Healthcare Organizations — nurses registries; licensed
                                                                        Note: This definition does not apply to Hospice Program
     mental health, freestanding public health, rehabilitation,
                                                                        Services. For Participating Providers for Hospice Program
     and Outpatient clinics not MD owned; portable X-ray
                                                                        Services, see the Participating Hospice or Participating Hos-
     companies; lay-owned independent laboratories; blood
                                                                        pice Agency definitions above.
     banks; speech and hearing centers; dental laboratories;
     dental supply companies; nursing homes; ambulance                  Physician — a licensed Doctor of Medicine, clinical psy-
     companies; Easter Seal Society; American Cancer Soci-              chologist, research psychoanalyst, dentist, licensed clinical
     ety, and Catholic Charities.                                       social worker, optometrist, chiropractor, podiatrist, audiolo-
                                                                        gist, registered physical therapist, or licensed marriage and
Outpatient Facility — a licensed facility, not a Physician's
                                                                        family therapist.
office or Hospital, that provides medical and/or surgical Ser-
vices on an Outpatient basis.                                           Physician Member — a Doctor of Medicine who has en-
                                                                        rolled with the Claims Administrator as a Physician Member.
Participating Ambulatory Surgery Center — an Outpa-
tient surgery facility which:                                           Preferred Dialysis Center — a dialysis services facility
                                                                        which has contracted with the Claims Administrator to pro-
1) is either licensed by the state of California as an ambula-
                                                                        vide dialysis services on an Outpatient basis and accept re-
   tory surgery center or is a licensed facility accredited by
                                                                        imbursement at negotiated rates.
   an ambulatory surgery center accrediting body; and,
                                                                        Preferred Hemophilia Infusion Provider — a provider that
2) provides services as a free-standing ambulatory surgery
                                                                        has contracted with the Claims Administrator to furnish
   center which is licensed separately and bills separately
                                                                        blood factor replacement products and services for in-home
   from a Hospital and is not otherwise affiliated with a
                                                                        treatment of blood disorders such as hemophilia and accept
   Hospital; and,
                                                                        reimbursement at negotiated rates, and that has been desig-
3) has contracted with the Claims Administrator to provide              nated as a contracted Hemophilia Infusion Provider by the
   Services on an Outpatient basis.                                     Claims Administrator.




                                                                   58
Preferred Hospital — a Hospital under contract to the                   4.   For a provider anywhere, other than in California, within
Claims Administrator which has agreed to furnish Services                    or outside of the United States, which has a contract with
and accept reimbursement at negotiated rates, and which has                  the local Blue Cross and/or Blue Shield plan, the amount
been designated as a Preferred Hospital by the Claims Ad-                    that the provider and the local Blue Cross and/or Blue
ministrator.                                                                 Shield plan have agreed by contract will be accepted as
                                                                             payment in full for service rendered; or
Preferred Provider — a Physician Member, a Preferred
Hospital, a Preferred Dialysis Center, or a Participating Pro-          5.   For a non-participating provider (i.e., that does not con-
vider.                                                                       tract with a local Blue Cross and/or Blue Shield plan)
                                                                             anywhere, other than in California, within or outside of
Skilled Nursing Facility — a facility with a valid license
                                                                             the United States, who provides Services on other than
issued by the California Department of Health Services as a
                                                                             an emergency basis, the amount that the local Blue
Skilled Nursing Facility or any similar institution licensed
                                                                             Cross and/or Blue Shield would have allowed for a non-
under the laws of any other state, territory, or foreign coun-
                                                                             participating provider performing the same services. If
try.
                                                                             the local plan has no non-participating provider allow-
                                                                             ance, the Claims Administrator will assign the Allow-
ALL OTHER DEFINITIONS                                                        able Amount used for a Non-Participating Provider in
Whenever any of the following terms are capitalized in this                  California.
booklet, they will have the meaning stated below:                       Benefits (Services) — those Services which a Member is
Accidental Injury — definite trauma resulting from a sud-               entitled to receive pursuant to the Plan Document.
den, unexpected and unplanned event, occurring by chance,               Calendar Year — a period beginning on January 1 of any
caused by an independent, external source.                              year and terminating on January 1 of the following year.
Activities of Daily Living (ADL) — mobility skills required             Chronic Care — care (different from Acute Care) furnished
for independence in normal everyday living. Recreational,               to treat an illness, injury or condition, which does not require
leisure, or sports activities are not included.                         hospitalization (although confinement in a lesser facility may
Acute Care — care rendered in the course of treating an                 be appropriate), which may be expected to be of long dura-
illness, injury or condition marked by a sudden onset or                tion without any reasonably predictable date of termination,
change of status requiring prompt attention, which may in-              and which may be marked by recurrences requiring continu-
clude hospitalization, but which is of limited duration and             ous or periodic care as necessary.
which is not expected to last indefinitely.                             Claims Administrator — the claims payor designated by
Allowable Amount — the Claims Administrator Allowance                   the Employer to adjudicate claims and provide other services
(as defined below) for the Service (or Services) rendered, or           as mutually agreed. Blue Shield of California has been des-
the provider’s billed charge, whichever is less. The Claims             ignated the Claims Administrator.
Administrator Allowance, unless otherwise specified for a               Close Relative — the spouse, Domestic Partner, children,
particular service elsewhere in this booklet, is:                       brothers, sisters, or parents of a covered Member.
1.   For a Participating Provider, the amount that the Pro-             Copayment — the amount that a Member is required to pay
     vider and the Claims Administrator have agreed by con-             for specific Covered Services after meeting any applicable
     tract will be accepted as payment in full for the Services         Deductible.
     rendered; or
                                                                        Cosmetic Surgery — surgery that is performed to alter or
2.   For a non-participating provider anywhere within or                reshape normal structures of the body to improve appearance.
     outside of the United States who provides Emergency
     Services:                                                          Covered Services (Benefits) — those Services which a
                                                                        Member is entitled to receive pursuant to the terms of the
     a.   Physicians and Hospitals – the Reasonable and Cus-            Plan.
          tomary Charge;
                                                                        Custodial or Maintenance Care — care furnished in the
     b.   All other providers – the provider’s billed charge for        home primarily for supervisory care or supportive services,
          covered Services, unless the provider and the local           or in a facility primarily to provide room and board (which
          Blue Cross and/or Blue Shield have agreed upon                may or may not include nursing care, training in personal
          some other amount; or                                         hygiene and other forms of self care and/or supervisory care
3.   For a non-participating provider in California, including          by a Physician) or care furnished to a Member who is men-
     an Other Provider, who provides Services on other than             tally or physically disabled, and
     an emergency basis, the amount the Claims Administra-              1.   who is not under specific medical, surgical or psychiatric
     tor would have allowed for a Participating Provider per-                treatment to reduce the disability to the extent necessary
     forming the same service in the same geographical area;                 to enable the patient to live outside an institution provid-
     or                                                                      ing care; or


                                                                   59
2.   when, despite medical, surgical or psychiatric treatment,                         (1) above. In no event will coverage be contin-
     there is no reasonable likelihood that the disability will                        ued beyond the date when the Dependent child
     be so reduced.                                                                    becomes ineligible for coverage under this Plan
                                                                                       for any reason other than attained age.
Deductible — the Calendar Year amount which you must
pay for specific Covered Services that are a Benefit of the              Domestic Partner — an individual who is personally related
Plan before you become entitled to receive certain Benefit               to the Member by a domestic partnership that meets the fol-
payments from the Plan for those Services.                               lowing requirements:
Dependent —                                                              1.   Domestic partners are two adults who have chosen to
                                                                              share one another’s lives in an intimate and committed
1.   a Participant’s legally married spouse who is:
                                                                              relationship of mutual caring;
     a.    not covered for Benefits as a Participant; and
                                                                         2.   Both persons have filed a Declaration of Domestic Part-
     b.    not legally separated from the Participant;                        nership with the California Secretary of State. California
                                                                              state registration is limited to same sex domestic partners
     or,
                                                                              and only those opposite sex partners where one partner
2.   a Participant’s Domestic Partner who is not covered for                  is at least 62 and eligible for Social Security based on
     Benefits as a Participant;                                               age.
     or,                                                                 The domestic partnership is deemed created on the date the
                                                                         Declaration of Domestic Partnership is filed with the Califor-
3.   a child of, adopted by, or in legal guardianship of the             nia Secretary of State.
     Participant, spouse, or Domestic Partner. This category
     includes any stepchild or child placed for adoption or              Domiciliary Care — care provided in a Hospital or other
     any other child for whom the Participant, spouse, or                licensed facility because care in the patient's home is not
     Domestic Partner has been appointed as a non-temporary              available or is unsuitable.
     legal guardian by a court of appropriate legal jurisdic-
                                                                         Durable Medical Equipment — equipment designed for
     tion, who is not covered for Benefits as a Participant              repeated use which is medically necessary to treat an illness
     who is less than 26 years of age                                    or injury, to improve the functioning of a malformed body
and who has been enrolled and accepted by the Claims Ad-                 member, or to prevent further deterioration of the patient's
ministrator as a Dependent and has maintained participation              medical condition. Durable Medical Equipment includes
in accordance with the Claims Administrator Plan.                        items such as wheelchairs, Hospital beds, respirators, and
                                                                         other items that the Claims Administrator determines are
Note: Children of Dependent children (i.e., grandchildren of             Durable Medical Equipment.
the Participant, spouse, or Domestic Partner) are not Depend-
ents unless the Participant, spouse, or Domestic Partner has             Emergency Services — services provided for an unexpected
adopted or is the legal guardian of the grandchild.                      medical condition, including a psychiatric emergency medi-
                                                                         cal condition, manifesting itself by acute symptoms of suffi-
4.   If coverage for a Dependent child would be terminated               cient severity (including severe pain) that the absence of im-
     because of the attainment of age 26, and the Dependent              mediate medical attention could reasonably be expected to
     child is disabled, Benefits for such Dependent will be              result in any of the following:
     continued upon the following conditions:
                                                                         1.   placing the patient's health in serious jeopardy;
     a.    the child must be chiefly dependent upon the Par-
           ticipant, spouse, or Domestic Partner for support             2.   serious impairment to bodily functions;
           and maintenance;                                              3.   serious dysfunction of any bodily organ or part.
     b.    the Participant, spouse, or Domestic Partner submits
                                                                         Employee — is the person who, by meeting the Plan’s eligi-
           to the Claims Administrator a Physician's written             bility requirements for Employees, is allowed to choose
           certification of disability within 60 days from the           membership under this Plan for himself or herself and his or
           date of the Employer's or the Claims Administra-
                                                                         her eligible Dependents.
           tor's request; and
                                                                         Employer — a public agency that has at least 2 employees
     c.    thereafter, certification of continuing disability and        and that is actively engaged in business or service, in which a
           dependency from a Physician is submitted to the
                                                                         bona fide employer-employee relationship exists, in which
           Claims Administrator on the following schedule:               the majority of employees were employed within this state,
           (1) within 24 months after the month when the De-             and which was not formed primarily for purposes of buying
               pendent would otherwise have been terminated;             health care coverage or insurance.
               and                                                       Enrollment Date — the first day of coverage, or if there is a
           (2) annually thereafter on the same month when                waiting period, the first day of the waiting period (typically,
               certification was made in accordance with item            date of hire).


                                                                    60
Experimental or Investigational in Nature — any treat-                   1.   The eligible Employee or Dependent meets all of the
ment, therapy, procedure, drug or drug usage, facility or fa-                 following requirements of (a.), (b.), (c.) and (d.):
cility usage, equipment or equipment usage, device or device
                                                                              a.   The Employee or Dependent was covered under an-
usage, or supplies which are not recognized in accordance
                                                                                   other employer health benefit plan at the time he or
with generally accepted professional medical standards as
                                                                                   she was offered enrollment under this Plan; and
being safe and effective for use in the treatment of the illness,
injury, or condition at issue. Services which require approval                b.   The Employee or Dependent certified, at the time of
by the Federal government or any agency thereof, or by any                         the initial enrollment, that coverage under another
State government agency, prior to use and where such ap-                           employer health benefit plan was the reason for de-
proval has not been granted at the time the services or sup-                       clining enrollment, provided that, if he or she was
plies were rendered, shall be considered experimental or in-                       covered under another employer health plan, he or
vestigational in nature. Services or supplies which them-                          she was given the opportunity to make the certifica-
selves are not approved or recognized in accordance with                           tion required and was notified that failure to do so
accepted professional medical standards, but nevertheless are                      could result in later treatment as a Late Enrollee;
authorized by law or by a government agency for use in test-                       and
ing, trials, or other studies on human patients, shall be con-
                                                                              c.   The Employee or Dependent has lost or will lose
sidered experimental or investigational in nature.
                                                                                   coverage under another employer health benefit
Family — the Participant and all enrolled Dependents.                              plan as a result of termination of his or her employ-
                                                                                   ment or of the individual through whom he or she
Family Coverage — coverage provided for two or more
                                                                                   was covered as a Dependent, change in his or her
Members, as defined herein.
                                                                                   employment status or of the individual through
Incurred — a charge will be considered to be “Incurred” on                         whom he or she was covered as a Dependent, ter-
the date the particular service or supply which gives rise to it                   mination of the other plan’s coverage, exhaustion of
is provided or obtained.                                                           COBRA continuation coverage, cessation of an em-
                                                                                   ployer’s contribution toward his or her coverage,
Individual (Self-only) Coverage — Coverage provided for
                                                                                   death of the individual through whom he or she was
only one Participant, as defined herein.
                                                                                   covered as a Dependent, or legal separation, divorce
Infertility — the Member must actively be trying to con-                           or termination of a domestic partnership; and
ceive and has:
                                                                              d.   The Employee or Dependent requests enrollment
1.   the presence of a demonstrated bodily malfunction rec-                        within 31 days after termination of coverage or em-
     ognized by a licensed Doctor of Medicine as a cause of                        ployer contribution toward coverage provided under
     not being able to conceive; or                                                another employer health benefit plan; or
2.   for women age 35 and less, failure to achieve a success-            2.   The Employer offers multiple health benefit plans and
     ful pregnancy (live birth) after 12 months or more of                    the eligible Employee elects this Plan during an open en-
     regular unprotected intercourse; or                                      rollment period; or
3.   for women over age 35, failure to achieve a successful              3.   A court has ordered that coverage be provided for a
     pregnancy (live birth) after 6 months or more of regular                 spouse or Domestic Partner or minor child under a cov-
     unprotected intercourse; or                                              ered Employee’s health benefit Plan. The health Plan
                                                                              shall enroll a Dependent child within 31 days of presen-
4.   failure to achieve a successful pregnancy (live birth)                   tation of a court order by the district attorney, or upon
     after six cycles of artificial insemination supervised by a
                                                                              presentation of a court order or request by a custodial
     Physician (the initial six cycles are not a benefit of this              party, as described in Section 3751.5 of the Family
     Plan); or                                                                Code; or
5.   three or more pregnancy losses.
                                                                         4.   For eligible Employees or Dependents who fail to elect
Inpatient — an individual who has been admitted to a Hos-                     coverage in this Plan during their initial enrollment pe-
pital as a registered bed patient and is receiving services under             riod, the Plan cannot produce a written statement from
the direction of a Physician.                                                 the Employer stating that prior to declining coverage, the
                                                                              Employee or Dependent, or the individual through
Late Enrollee — an eligible Employee or Dependent who                         whom he or she was eligible to be covered as a Depend-
has declined enrollment in this Plan at the time of the initial               ent, was provided with and signed acknowledgment of a
enrollment period, and who subsequently requests enrollment                   Refusal of Personal Coverage form specifying that fail-
in this Plan; provided that the initial enrollment period shall               ure to elect coverage during the initial enrollment period
be a period of at least 30 days. However, an eligible Em-                     permits the Plan to impose, at the time of his or her later
ployee or Dependent shall not be considered a Late Enrollee                   decision to elect coverage, an exclusion from coverage
if any of the following paragraphs (1.), (2.), (3.), (4.), (5.),              for a period of 12 months, unless he or she meets the cri-
(6.) or (7.) is applicable:                                                   teria specified in paragraphs (1.), (2.) or (3.) above; or


                                                                    61
5.   For eligible Employees or Dependents who were eligible                   c.   for personal comfort;
     for coverage under the Healthy Families Program or
                                                                              d.   in a pain management center to treat or cure chronic
     Medi-Cal and whose coverage is terminated as a result
                                                                                   pain; and
     of the loss of such eligibility, provided that enrollment is
     requested no later than 60 days after the termination of                 e.   for Inpatient Rehabilitation that can be provided on
     coverage; or                                                                  an Outpatient basis.
6.   For eligible Employees or Dependents who are eligible               4.   The Claims Administrator reserves the right to review all
     for the Healthy Families Program or the Medi-Cal pre-                    claims to determine whether services are medically nec-
     mium assistance program and who request enrollment                       essary, and may use the services of Physician consult-
     within 60 days of the notice of eligibility for these pre-               ants, peer review committees of professional societies or
     mium assistance programs; or                                             Hospitals, and other consultants.
7.   For eligible Employees who decline coverage during the              Member — either a Participant or Dependent.
     initial enrollment period and subsequently acquire De-
                                                                         Mental Health Condition — for the purposes of this Plan,
     pendents through marriage, establishment of domestic
     partnership, birth, or placement for adoption, and who              means those conditions listed in the “Diagnostic & Statistical
     enroll for coverage for themselves and their Dependents             Manual of Mental Disorders Version IV” (DSM4), except as
                                                                         stated herein, and no other conditions. Mental Health Condi-
     within 31 days from the date of marriage, establishment
     of domestic partnership, birth, or placement for adop-              tions include Severe Mental Illnesses and Serious Emotional
     tion.                                                               Disturbances of a Child, but do not include any services relat-
                                                                         ing to the following:
Medical Necessity (Medically Necessary) —
                                                                         1.   Diagnosis or treatment of Substance Abuse Conditions;
The Benefits of this Plan are provided only for Services
which are medically necessary.                                           2.   Diagnosis or treatment of conditions represented by V
                                                                              Codes in DSM4;
1.   Services which are medically necessary include only
     those which have been established as safe and effective,            3.   Diagnosis or treatment of any conditions listed in DSM4
     are furnished under generally accepted professional                      with the following codes:
     standards to treat illness, injury or medical condition,                 294.8, 294.9, 302.80 through 302.90, 307.0, 307.3,
     and which, as determined by the Claims Administrator,                    307.9, 312.30 through 312.34, 313.9, 315.2, 315.39
     are:                                                                     through 316.0.
     a.   consistent with the Claims Administrator medical               Mental Health Services — Services provided to treat a
          policy;                                                        Mental Health Condition.
     b.   consistent with the symptoms or diagnosis;                     Occupational Therapy — treatment under the direction of a
     c.   not furnished primarily for the convenience of the             Doctor of Medicine and provided by a certified occupational
          patient, the attending Physician or other provider;            therapist, utilizing arts, crafts, or specific training in daily
                                                                         living skills, to improve and maintain a patient’s ability to
          and
                                                                         function.
     d.   furnished at the most appropriate level which can be
          provided safely and effectively to the patient.                Open Enrollment Period — that period of time set forth in
                                                                         the plan document during which eligible Employees and their
2.   If there are two or more medically necessary services               Dependents may transfer from another health benefit plan
     that may be provided for the illness, injury or medical             sponsored by the Employer to the Preferred Plan.
     condition, the Claims Administrator will provide bene-
                                                                         Orthosis (Orthotics) — an orthopedic appliance or appara-
     fits based on the most cost-effective service.
                                                                         tus used to support, align, prevent or correct deformities, or
3.   Hospital Inpatient Services which are medically neces-              to improve the function of movable body parts.
     sary include only those Services which satisfy the above
                                                                         Outpatient — an individual receiving services but not as an
     requirements, require the acute bed-patient (overnight)
     setting, and which could not have been provided in the              Inpatient.
     Physician's office, the Outpatient department of a Hospi-           Partial Hospitalization/Day Treatment Program — a
     tal, or in another lesser facility without adversely affect-        treatment program that may be free-standing or Hospital-
     ing the patient's condition or the quality of medical care          based and provides services at least 5 hours per day and at
     rendered. Inpatient services not medically necessary in-            least 4 days per week. Patients may be admitted directly to
     clude hospitalization:                                              this level of care, or transferred from acute Inpatient care
     a.   for diagnostic studies that could have been provided           following acute stabilization.
          on an Outpatient basis;                                        Participant — an employee who has been accepted by the
     b.   for medical observation or evaluation;                         Employer and enrolled by the Claims Administrator as a Par-


                                                                    62
ticipant and who has maintained enrollment in accordance               In the event there is a new recommendation or guideline in
with this Plan.                                                        any of the resources described in paragraphs 1. through 4.
                                                                       above, the new recommendation will be covered as a Preven-
Participating Employer — a Participating Employer is a
                                                                       tive Health Service no later than 12 months following the
California city or county government. Specific qualifications
                                                                       issuance of the recommendation.
of a Participating Employer are stipulated in the participation
agreement.                                                             Program Administrator — CSAC Excess Insurance
                                                                       Authority.
Physical Therapy — treatment provided by a Doctor of
Medicine or under the direction of a Doctor of Medicine                Prosthesis (Prosthetics) — an artificial part, appliance or
when provided by a registered physical therapist, certified            device used to replace or augment a missing or impaired part
occupational therapist or licensed doctor of podiatric medi-           of the body.
cine. Treatment utilizes physical agents and therapeutic pro-
                                                                       Reasonable and Customary Charge — in California: The
cedures, such as ultrasound, heat, range of motion testing,
                                                                       lower of (1) the provider’s billed charge, or (2) the amount
and massage, to improve a patient’s musculoskeletal, neuro-
                                                                       determined by the Claims Administrator to be the reasonable
muscular and respiratory systems.
                                                                       and customary value for the services rendered by a non-Plan
Plan — the Claims Administrator Preferred Savings Plan for             Provider based on statistical information that is updated at
eligible Employees of the Employer.                                    least annually and considers many factors including, but not
                                                                       limited to, the provider’s training and experience, and the
Plan Sponsor — is the designated party that sets up a
                                                                       geographic area where the services are rendered; Outside of
healthcare plan for the benefit of the Employer’s Employees.
                                                                       California: The lower of (1) the provider’s billed charge, or,
The responsibilities of the Plan Sponsor include determining
                                                                       (2) the amount, if any, established by the laws of the state to
membership parameters, investment choices and providing
                                                                       be paid for Emergency Services.
contribution payments.
                                                                       Reconstructive Surgery — surgery to correct or repair ab-
Preventive Health Services — mean those primary preven-
                                                                       normal structures of the body caused by congenital defects,
tive medical Covered Services, including related laboratory
                                                                       developmental abnormalities, trauma, infection, tumors, or
services, for early detection of disease as specifically listed
                                                                       disease to do either of the following: 1) to improve function,
below:
                                                                       or 2) to create a normal appearance to the extent possible;
1.   Evidence-based items or services that have in effect a            dental and orthodontic Services that are an integral part of
     rating of “A” or “B” in the current recommendations of            Reconstructive Surgery for cleft palate procedures.
     the United States Preventive Services Task Force;
                                                                       Rehabilitation — Inpatient or Outpatient care furnished
2.   Immunizations that have in effect a recommendation                primarily to restore an individual’s ability to function as
     from either the Advisory Committee on Immunization                normally as possible after a disabling illness or injury. Reha-
     Practices of the Centers for Disease Control and Preven-          bilitation services may consist of Physical Therapy, Occupa-
     tion, or the most current version of the Recommended              tional Therapy, and/or Respiratory Therapy and are provided
     Childhood Immunization Schedule/United States, jointly            with the expectation that the patient has restorative potential.
     adopted by the American Academy of Pediatrics, the                Benefits for Speech Therapy are described in the section on
     Advisory Committee on Immunization Practices, and the             Speech Therapy Benefits.
     American Academy of Family Physicians;
                                                                       Residential Care — services provided in a facility or a free-
3.   With respect to infants, children, and adolescents, evi-          standing residential treatment center that provides over-
     dence-informed preventive care and screenings provided            night/extended-stay services for Members who do not qualify
     for in the comprehensive guidelines supported by the              for Acute Care or Skilled Nursing Services. This definition
     Health Resources and Services Administration;                     does not apply to services rendered under the Hospice Pro-
                                                                       gram Benefit.
4.   With respect to women, such additional preventive care
     and screenings not described in paragraph 1. as provided          Respiratory Therapy — treatment, under the direction of a
     for in comprehensive guidelines supported by the Health           Doctor of Medicine and provided by a certified respiratory
     Resources and Services Administration.                            therapist, to preserve or improve a patient’s pulmonary func-
                                                                       tion.
Preventive Health Services include, but are not limited to,
cancer screening (including, but not limited to, colorectal            Serious Emotional Disturbances of a Child — refers to
cancer screening, cervical cancer and HPV screening, breast            individuals who are minors under the age of 18 years who
cancer screening and prostate cancer screening), osteoporosis
                                                                       1.   have one or more mental disorders in the most recent
screening, screening for blood lead levels in children at risk
                                                                            edition of the Diagnostic and Statistical Manual of Men-
for lead poisoning, and health education. More information
                                                                            tal Disorders (other than a primary substance use disor-
regarding covered Preventive Health Services is available at
                                                                            der or developmental disorder), that results in behavior
http://www.blueshieldca.com/preventive or by calling Cus-
                                                                            inappropriate for the child’s age according to expected
tomer Service.
                                                                            developmental norms, and


                                                                  63
2.   meet the criteria in paragraph (2) of subdivision (a) of               formulated to have less than one gram of protein per
     Section 5600.3 of the Welfare and Institutions Code.                   serving;
     This section states that members of this population shall
                                                                       2.   Used in place of normal food products, such as grocery
     meet one or more of the following criteria:
                                                                            store foods, used by the general population.
     (a) As a result of the mental disorder the child has sub-
                                                                       Speech Therapy — treatment, under the direction of a Phy-
         stantial impairment in at least two of the following
                                                                       sician and provided by a licensed speech pathologist or
         areas: self-care, school functioning, family relation-
                                                                       speech therapist, to improve or retrain a patient’s vocal skills
         ships, or ability to function in the community; and
                                                                       which have been impaired by diagnosed illness or injury.
         either of the following has occurred: the child is at
         risk of removal from home or has already been re-             Subacute Care — skilled nursing or skilled rehabilitation
         moved from the home or the mental disorder and                provided in a Hospital or Skilled Nursing Facility to patients
         impairments have been present for more than 6                 who require skilled care such as nursing services, physical,
         months or are likely to continue for more than one            occupational or speech therapy, a coordinated program of
         year without treatment;                                       multiple therapies or who have medical needs that require
                                                                       daily Registered Nurse monitoring. A facility which is pri-
     (b) The child displays one of the following: psychotic
                                                                       marily a rest home, convalescent facility or home for the
         features, risk of suicide or risk of violence due to a
                                                                       aged is not included.
         mental disorder.
                                                                       Substance Abuse Condition — for the purposes of this
Services — includes Medically Necessary healthcare ser-
                                                                       Plan, means any disorders caused by or relating to the recur-
vices and Medically Necessary supplies furnished incident to
                                                                       rent use of alcohol, drugs, and related substances, both legal
those services.
                                                                       and illegal, including but not limited to, dependence, intoxi-
Severe Mental Illnesses — conditions with the following                cation, biological changes and behavioral changes.
diagnoses: schizophrenia, schizo affective disorder, bipolar
                                                                       Total Disability (or Totally Disabled) —
disorder (manic depressive illness), major depressive disor-
ders, panic disorder, obsessive-compulsive disorder, perva-            1.   in the case of an Employee or Member otherwise eligi-
sive developmental disorder or autism, anorexia nervosa,                    ble for coverage as an Employee, a disability which pre-
bulimia nervosa.                                                            vents the individual from working with reasonable con-
                                                                            tinuity in the individual's customary employment or in
Special Food Products — a food product which is both of
                                                                            any other employment in which the individual reasona-
the following:
                                                                            bly might be expected to engage, in view of the individ-
1.   Prescribed by a Physician or nurse practitioner for the                ual's station in life and physical and mental capacity;
     treatment of phenylketonuria (PKU) and is consistent
                                                                       2.   in the case of a Dependent, a disability which prevents
     with the recommendations and best practices of qualified
                                                                            the individual from engaging with normal or reasonable
     health professionals with expertise germane to, and ex-
                                                                            continuity in the individual's customary activities or in
     perience in the treatment and care of, phenylketonuria
                                                                            those in which the individual otherwise reasonably
     (PKU). It does not include a food that is naturally low in
                                                                            might be expected to engage, in view of the individual's
     protein, but may include a food product that is specially
                                                                            station in life and physical and mental capacity.




                                                                  64
              Supplement A — Substance Abuse Condition Benefits

Summary of Benefits
                               Benefit                                                  Member Copayment1
     Benefits are provided for Services for Substance Abuse
    Conditions (including Partial Hospitalization2) as described in
                          this Supplement.
                                                                           Participating Provider      Non-Participating Provider
    Hospital Facility Services
    Inpatient Services                                                 Your Plan’s Hospital           Your Plan’s Hospital Benefits
                                                                       Benefits (Facility Ser-        (Facility Services), Inpatient
                                                                       vices), Inpatient Services     Services Copayment
                                                                       Copayment
    Outpatient Services                                                Your Plan’s Hospital           Your Plan’s Hospital Benefits
                                                                       Benefits (Facility Ser-        (Facility Services), Outpatient
                                                                       vices), Outpatient Ser-        Services, Services for illness or
                                                                       vices, Services for illness    injury Copayment
                                                                       or injury Copayment
    Partial Hospitalization2                                           Your Plan’s Ambulatory         Your Plan’s Ambulatory Sur-
                                                                       Surgery Center Benefits        gery Center Benefits Copay-
                                                                       Copayment applies per          ment applies per Episode
                                                                       Episode
    Professional (Physician) Services
    Inpatient Services                                                 Your Plan’s Professional       Your Plan’s Professional (Phy-
                                                                       (Physician) Benefits, In-      sician) Benefits, Inpatient Phy-
                                                                       patient Physician Benefits     sician Benefits Copayment
                                                                       Copayment
    Outpatient Service                                                 Your Plan’s Professional       Your Plan’s Professional (Phy-
                                                                       (Physician) Benefits, of-      sician) Benefits, office visits
                                                                       fice visits Copayment          Copayment
1      The Copayments below are subject to the Deductible, Member Maximum Calendar Year Copayment Responsibility and
       other applicable provisions of your Plan.
2
       Partial Hospitalization/Day Treatment Program is a treatment program that may be free-standing or Hospital-based and pro-
       vides Services at least 5 hours per day and at least 4 days per week. Patients may be admitted directly to this level of care,
       or transferred from acute Inpatient care following acute stabilization.


In addition to the Benefits listed described in your Benefit                   Outpatient Partial Hospitalization;
Booklet, your Plan provides coverage for Substance Abuse
                                                                               Intensive Outpatient Care; and,
Condition Services as described in this Supplement. All Ser-
vices must be Medically Necessary. Residential care is not                     Outpatient electroconvulsive therapy (ECT).
covered. For a definition of Substance Abuse Condition, see
the Definitions section of your booklet.                                   Prior to obtaining the Substance Abuse Condition Services
                                                                           listed above, you or your Physician must call the Claims Ad-
This Supplemental Benefit does not include Inpatient Ser-                  ministrator at the Customer Service telephone number indi-
vices which are Medically Necessary to treat the acute medi-               cated on the back of the Member’s identification card for
cal complications of detoxification, which are covered as part             prior authorization.
of the medical Benefits of your health plan and not consid-
ered to be treatment of the Substance Abuse Condition itself.              Failure to obtain prior authorization or to follow the recom-
                                                                           mendations of the Claims Administrator for Non-Emergency
Prior authorization by the Claims Administrator is required                Substance Abuse Condition Services as specified above will
for Non-Emergency Substance Abuse Condition Services as                    result in the following:
specified below.
     Inpatient Hospital and Professional Services;

                                                                      65
for Inpatient Hospital and Professional Services, an ad-        Benefits are provided for Medically Necessary Services for
ditional Member payment of $250 for each Hospital               Substance Abuse Conditions, as defined in your booklet, and
admission;                                                      as specified in this Supplement. Residential care is not cov-
                                                                ered.
for Outpatient Partial Hospitalization, Intensive Outpa-
tient Care; and ECT services, non-payment of services           This Benefit is subject to the general provisions, limitations
by the Claims Administrator.                                    and exclusions listed in your Benefit Booklet.




                                                           66
                   Supplement B — Hearing Aid Services Benefit

Summary of Benefits
                          Benefit                                                     Member Copayment
Hearing aid Services as described in this Supplement                               20% for two standard hearing aids
                                                                      Benefits are limited to a maximum allowance of $700 every
                                                                                                24 months

Introduction                                                           The following services and supplies are not covered:

In addition to the Benefits listed in your Benefit Booklet,            1.   Purchase of batteries or other ancillary equipment, ex-
your Plan provides coverage for hearing aid Services, subject               cept those covered under the terms of the initial hearing
to the conditions and limitations listed below.                             aid purchase;

The hearing aid Services Benefit provides a combined                   2.   Charges for a hearing aid which exceed specifications
maximum allowance every 24 months as shown on the Sum-                      prescribed for correction of a hearing loss;
mary of Benefits towards covered hearing aids and Services             3.   Replacement parts for hearing aids, repair of hearing
as specified below. The hearing aid Services Benefit is sepa-               aids after the covered warranty period and replacement
rate and apart from the other Benefits described in your                    of hearing aids more than once in any period of 24-
Benefit Booklet. You are not required to use a Claims Ad-                   month period;
ministrator Preferred Provider to obtain these services as the
Claims Administrator does not maintain a network of con-               4.   Surgically implanted hearing devices.
tracted providers for these services. You may obtain these             The Calendar Year Deductible does apply to the Services
services from any provider of your choosing and submit a               provided in this hearing aid Services Benefit.
claim to the Claims Administrator for reimbursement for
covered Services up to the combined maximum allowance.                 Hearing aids and ancillary equipment are included in the
For information on submitting a claim, see the “Submitting a           calculation of the Participant’s maximum Calendar Year Co-
Claim Form” paragraphs in the Introduction section of your             payment responsibility.
Benefit Booklet.                                                       This Benefit is subject to the general provisions, limitations
                                                                       and exclusions listed in your Benefit Booklet.
Benefits
Hearing Aids and Ancillary Equipment
The Benefit allowance is provided for hearing aids and ancil-
lary equipment up to the maximum per Member shown on
the Summary of Benefits in any 24-month period. You are
responsible for the cost of any hearing aid Services which are
in excess of this Benefit allowance.
The hearing aid Benefit includes: a hearing aid instrument,
monaural or binaural including ear mold(s), the initial bat-
tery, cords and other ancillary equipment. The Benefit also
includes visits for fitting, counseling and adjustments.




                                                                 67
                         For claims submission and information contact your appropriate
                                        Claims Administrator location.
                                       Participants may call Customer Service toll free:

                                                       1-800-642-6155


                    The hearing impaired may call the Claims Administrator’s Customer Service Department
                         through the Claims Administrator’s toll-free TTY number at 1-800-241-1823.


                                Benefits Management Program Telephone Numbers
                   For Prior Authorization: Please call the Customer Service telephone number indicated on
                                         the back of the Member’s identification card.


                For prior authorization of Benefits Management Program Radiological Services: 1-888-642-2583


                               Please refer to the Benefits Management Program section of this
                                                Benefit Booklet for information.




Please direct correspondence to:

                                        The Claims Administrator
                                        P.O. Box 272540
                                        Chico, CA 95927-2540




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