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EPO Plan

VIEWS: 3 PAGES: 60

									                                                        EPO Plan




                                                                                     An Independent Member of the Blue Shield Association
                                                      ASO Benefit Booklet
                                             CSAC Excess Insurance Authority
                                                County of Santa Barbara
                                                      Group Number: E10060
                                                   Effective Date: January 1, 2010




Claims Administered by Blue Shield of California
                               ASO Benefit Booklet




                                        PLEASE NOTE
Some hospitals and other providers do not provide one or more of the following services that may
be covered under your Plan and that you or your family member might need: family planning;
contraceptive services, including emergency contraception; sterilization, including tubal ligation
at the time of labor and delivery; infertility treatments; or abortion. You should obtain more in-
formation before you enroll. Call your prospective doctor, medical group, independent practice
association, or clinic, or call the health Plan at Customer Service telephone number listed at the
back of this booklet to ensure that you can obtain the health care services that you need.




aso ju (11/09)
The EPO Medical Plan
Participant Bill of Rights
As an EPO Medical 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 EPO Medical Plan,
     the Services we offer you, the Physicians and other          12. Communicate with and receive information from
     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.                            Medical 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.




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




                                                              3
TABLE OF CONTENTS
EPO SUMMARY OF BENEFITS ....................................................................................................................................................... 7
INTRODUCTION ........................................................................................................................................................................... 13
  Preferred Providers................................................................................................................................................................ 13
  Continuity of Care by a Terminated Provider ....................................................................................................................... 14
  Financial Responsibility for Continuity of Care Services ..................................................................................................... 14
ELIGIBILITY ................................................................................................................................................................................ 14
EFFECTIVE DATE OF COVERAGE................................................................................................................................................. 15
MEDICAL CARE BENEFITS .......................................................................................................................................................... 16
ANNUAL OPEN ENROLLMENT ..................................................................................................................................................... 16
SPECIAL ENROLLMENT EVENT ................................................................................................................................................... 16
EFFECTIVE DATE FOR LATE ENROLLEES ..................................................................................................................................... 16
RENEWAL OF PLAN ..................................................................................................................................................................... 16
SERVICES FOR EMERGENCY CARE .............................................................................................................................................. 17
SECOND MEDICAL OPINION POLICY ........................................................................................................................................... 17
HEALTH EDUCATION AND HEALTH PROMOTION SERVICES ....................................................................................................... 17
RETAIL-BASED HEALTH CLINICS ............................................................................................................................................... 17
NURSEHELP 24/7........................................................................................................................................................................ 17
THE CLAIMS ADMINISTRATOR ONLINE ...................................................................................................................................... 17
BENEFITS MANAGEMENT PROGRAM .......................................................................................................................................... 17
  Prior Authorization................................................................................................................................................................ 18
  Hospital and Skilled Nursing Facility Admissions................................................................................................................ 19
  Emergency Admission Notification ...................................................................................................................................... 19
  Hospital Inpatient Review ..................................................................................................................................................... 19
  Discharge Planning................................................................................................................................................................ 19
  Case Management ................................................................................................................................................................. 20
ADDITIONAL AND REDUCED PAYMENTS FOR FAILURE TO USE THE BENEFITS MANAGEMENT PROGRAM .................................. 20
DEDUCTIBLE............................................................................................................................................................................... 20
  Calendar Year Deductible (Medical Plan Deductible) .......................................................................................................... 20
MAXIMUM AGGREGATE PAYMENT AMOUNT ............................................................................................................................. 20
PAYMENT ................................................................................................................................................................................... 20
  Participant’s Maximum Calendar Year Copayment Responsibility ...................................................................................... 22
PRINCIPAL BENEFITS AND COVERAGES (COVERED SERVICES)................................................................................................... 22
  Acupuncture Benefits ............................................................................................................................................................ 22
  Allergy Testing and Treatment Benefits................................................................................................................................ 22
  Ambulance Benefits .............................................................................................................................................................. 22
  Ambulatory Surgery Center Benefits .................................................................................................................................... 22
  Chiropractic Benefits............................................................................................................................................................. 23
  Clinical Trial for Cancer Benefits ......................................................................................................................................... 23
  Diabetes Care Benefits .......................................................................................................................................................... 24
  Dialysis Centers Benefits ...................................................................................................................................................... 24
  Durable Medical Equipment Benefits ................................................................................................................................... 24
  Emergency Room Benefits.................................................................................................................................................... 24
  Family Planning benefits....................................................................................................................................................... 25
  Home Health Care Benefits................................................................................................................................................... 25
  Home Infusion/Home Injectable Therapy Benefits ............................................................................................................... 25
  Hospice Program Benefits ..................................................................................................................................................... 26
  Hospital Benefits (Facility Services) ..................................................................................................................................... 27
  Medical Treatment of Teeth, Gums, Jaw Joints or Jaw Bones Benefits................................................................................ 29
  Mental Health Benefits.......................................................................................................................................................... 30
  Orthotics Benefits.................................................................................................................................................................. 30
  Outpatient Prescription Drug Benefits................................................................................................................................... 30
  Outpatient X-ray, Pathology and Laboratory Benefits .......................................................................................................... 30
  PKU Related Formulas and Special Food Products Benefits ................................................................................................ 30
  Podiatric Services .................................................................................................................................................................. 31
  Pregnancy and Maternity Care Benefits ................................................................................................................................ 31
  Preventive Health Benefits .................................................................................................................................................... 31
  Professional (Physician) Benefits.......................................................................................................................................... 32
  Prosthetic Appliances Benefits.............................................................................................................................................. 33
  Radiological Procedures benefits (Requiring Prior Authorization)....................................................................................... 33

                                                                                              4
TABLE OF CONTENTS
  Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) ......................................................................... 33
  Skilled Nursing Facility Benefits .......................................................................................................................................... 34
  Speech Therapy Benefits....................................................................................................................................................... 34
  Transplant Benefits................................................................................................................................................................ 34
PRINCIPAL LIMITATIONS, EXCEPTIONS, EXCLUSIONS AND REDUCTIONS .................................................................................... 35
  General Exclusions................................................................................................................................................................ 35
  Medical Necessity Exclusion................................................................................................................................................. 38
  Limitations for Duplicate Coverage ...................................................................................................................................... 38
  Exception for Other Coverage............................................................................................................................................... 39
  Claims Review ...................................................................................................................................................................... 39
  Reductions ............................................................................................................................................................................. 39
  Termination of Benefits......................................................................................................................................................... 39
  Extension of Benefits ............................................................................................................................................................ 40
  Coordination of Benefits ....................................................................................................................................................... 40
GROUP CONTINUATION COVERAGE AND INDIVIDUAL CONVERSION PLAN ................................................................................. 41
  Continuation of Group Coverage .......................................................................................................................................... 41
  Continuation of Group Coverage for Members on Military Leave ....................................................................................... 43
  Individual Conversion Plan ................................................................................................................................................... 43
GENERAL PROVISIONS ................................................................................................................................................................ 44
  Liability of Participants in the Event of Non-Payment by the Claims Administrator ........................................................... 44
  Non-Assignability ................................................................................................................................................................. 44
  Plan Interpretation ................................................................................................................................................................. 44
  Confidentiality of Personal and Health Information.............................................................................................................. 44
  Access to Information............................................................................................................................................................ 45
  Independent Contractors........................................................................................................................................................ 45
CUSTOMER SERVICE ................................................................................................................................................................... 45
SETTLEMENT OF DISPUTES ......................................................................................................................................................... 45
DEFINITIONS ............................................................................................................................................................................... 46
  Plan Provider Definitions ...................................................................................................................................................... 46
  All Other Definitions............................................................................................................................................................. 47
SUPPLEMENT A — SUBSTANCE ABUSE CONDITION BENEFITS ................................................................................................... 53
SUPPLEMENT B — HEARING AID SERVICES BENEFIT ................................................................................................................. 54




                                                                                              5
This booklet constitutes only a summary of the health Plan. The health Plan document must be
consulted to determine 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 Medical Plan. Be sure you understand the Benefits of this Plan before Services are received.

                                                           NOTICE
Please read this Summary of Benefits booklet carefully to be sure you understand the Benefits, exclusions and general provi-
sions. It is your responsibility to keep informed about any changes in your health coverage.
Should you have any questions regarding your 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 cov-
erage, 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 indi-
vidual 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 Plans together with authority to control and manage the operation of the Benefit Plan.
The Plan Sponsor is 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 contribu-
tion 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
obligation 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 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.
                                                               6
                                      EPO Summary of Benefits

Note: See the end of this Summary of Benefits for important benefit footnotes.

Summary of Benefits1                                                                                 EPO Medical Plan
                                                               2
              Member Calendar Year Deductible                                                    Deductible
                 (Medical Plan Deductible)                                                      Responsibility
There is no Deductible requirement under this Plan.

               Member Maximum Calendar Year                                           Member Maximum Calendar
                 Copayment Responsibility3                                               Year Copayment3,4
Calendar Year Copayment maximum                                                     $1,500 per Member/$3,000 per Family


                          Member Maximum                                                     Maximum
                          Lifetime Benefits                                         Claims Administrator Payment
There is no maximum aggregate payment amount under this Plan. However,              No maximum
any stated Benefit maximums for specific Services (e.g., Calendar Year
maximum) or other Benefit limitations under this Plan will apply.

                                               Additional Payment(s)
Additional Payment(s) for Failure to Use the Benefits Management Program
Refer to the Benefits Management Program for any additional payments which may apply.

                                   Benefit                                                   Member Copayment3
Acupuncture Benefits
Acupuncture                                                                            $20 per visit
Covered Services up to a Benefit maximum of 12 visits per Member per Calen-            Claims Administrator Maximum Benefit
dar Year. Services by Doctors of Medicine and certificated acupuncturists              payment is $50 per visit
Allergy Testing and Treatment Benefits
Office visits (includes visits for allergy serum injections)                           $20 per visit
Ambulance Benefits
Emergency or authorized transport                                                      $50 per trip
Ambulatory Surgery Center Benefits
Outpatient surgery performed in an Ambulatory Surgery Center                           You pay nothing
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. Am-
bulatory surgery Services obtained from a Hospital or Hospital affiliated ambu-
latory surgery center will be paid as specified under Hospital Benefits (Facility
Services) in this Summary of Benefits.
Chiropractic Benefits
Chiropractic Services provided by a chiropractor up to a combined Benefit              $20 per visit
maximum with Rehabilitation Services of 26 visits per Member per Calendar
Year




                                                               7
                                    Benefit                                                 Member Copayment3
Clinical Trial for Cancer Benefits
Covered Services for Members who have been accepted into an approved clini-           You pay nothing
cal 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 Services shown in this Summary of Bene-
fits.
Diabetes Care Benefits
Devices, equipment and supplies                                                       You pay nothing6
Diabetes self-management training                                                     $20 per visit
Dialysis Center Benefits7
Dialysis Services                                                                     You pay nothing
Note: Dialysis Services may also be obtained from a Hospital. Dialysis Ser-
vices obtained from a Hospital will be paid as specified under Hospital Benefits
(Facility Services) in this Summary of Benefits.
Durable Medical Equipment Benefits
Durable Medical Equipment                                                             You pay nothing
Emergency Room Benefits
Emergency room Physician Services                                                     You pay nothing
Emergency room Services not resulting in admission                                    $100 per visit
Emergency room Services resulting in admission (billed as part of Inpatient           $250 per admission plus 20%
Hospital Services)
Family Planning Benefits
Counseling and consulting                                                             $20 per visit
Infertility
Diagnosis and treatment of cause of Infertility                                       50%
Intrauterine device (IUD)                                                             $20
Insertion and/or removal of intrauterine device (IUD)                                 $20 per visit
Elective abortion                                                                     $100 per surgery
    Physician Services Copayment in an office or Outpatient facility only. If pro-
    cedure is performed in a facility setting, an additional Services Copayment
    will apply.
Injectable contraceptives when administered by a Physician                            $20 per injection8
Note: The office visit Copayment shown below also applies
Physician office visits for diaphragm fitting or injectable contraceptives            $20 per visit
Tubal ligation                                                                        $100 per surgery
   In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital
   Services for a delivery/abdominal surgery.
    Physician Services Copayment in an office or Outpatient facility only. If pro-
    cedure is performed in a facility setting, an additional Services Copayment
    will apply.
Vasectomy                                                                             $75 per surgery
    Physician Services Copayment in an office or Outpatient facility only. If pro-
    cedure is performed in a facility setting, an additional Services Copayment
    will apply.
Home Health Care Benefits
Home health care agency Services including home visits by a nurse, home               20%
health aide, medical social worker, physical therapist, speech therapist, or occu-
pational therapist for up to a total of 100 visits by home health care agency pro-
viders per Member per Calendar Year
Medical supplies and related laboratory Services to the extent the Benefits would     20%
have been provided had the Member remained in the Hospital or Skilled Nursing
Facility

                                                                8
                                  Benefit                                                Member Copayment3
Home Infusion/Home Injectable Therapy Benefits
Home infusion/home injectable therapy and infusion nursing visits provided by      20%
a Home Infusion Agency (home infusion agency visits are not subject to the
visit limitation under Home Health Care Benefits)
Home self-administered injectable drugs are covered under the Outpatient Pre-
scription Drug Benefit if selected as an optional Benefit by your Employer, and
are described in a Supplement included with this booklet.
Hospice Program Benefits
Covered Services for Members who have been accepted into an approved Hos-
pice Program
All Hospice Program Benefits must be prior authorized by the Claims Adminis-
trator and must be received from a Participating Hospice Agency
24-hour Continuous Home Care                                                       20%
General Inpatient care                                                             20%
Inpatient Respite Care                                                             You pay nothing
Pre-hospice consultation                                                           You pay nothing
Routine home care                                                                  You pay nothing
Hospital Benefits (Facility Services)
Inpatient Emergency Facility Services                                              $250 per admission plus 20%
Inpatient Non-emergency Facility Services                                          $250 per admission plus 20%
Inpatient Medically Necessary skilled nursing Services including Subacute          20%
Care9
Inpatient Services to treat acute medical complications of detoxification          $250 per admission plus 20%
Outpatient dialysis Services7                                                      You pay nothing
Outpatient Services for radiation therapy, chemotherapy, treatment and neces-      You pay nothing
sary supplies
Outpatient Services for surgery and necessary supplies                             You pay nothing
Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Bene-
fits
Treatment of gum tumors, damaged natural teeth resulting from Accidental In-
jury, TMJ as specifically stated and orthognathic surgery for skeletal deformity
(be sure to read the Principal Benefits and Coverages (Covered Services) section
for a complete description)
Inpatient Hospital Services                                                        $250 per admission plus 20%
Office location                                                                    $20 per visit
Outpatient department of a Hospital                                                You pay nothing
Mental Health Benefits10
Inpatient Hospital Services11                                                      $250 per admission plus 20%
Inpatient Physician Services                                                       You pay nothing
Outpatient Mental Health Services                                                  $20 per visit12
Psychological testing                                                              You pay nothing
Orthotics Benefits
Office visits                                                                      $20 per visit
Orthotic equipment and devices                                                     You pay nothing
Outpatient Prescription Drug Benefits
Outpatient Prescription Drug Benefits if selected as an optional Benefit by your
Employer, are described in a Supplement included with this booklet
Outpatient X-ray, Pathology and Laboratory Benefits
Outpatient X-ray, pathology and laboratory                                         You pay nothing6




                                                             9
                                  Benefit                                               Member Copayment3
PKU Related Formulas and Special Food Products Benefits
PKU related formulas and Special Food Products                                    20%
The above Services must be prior authorized by the Claims Administrator.
Podiatric Benefits
Podiatric Services provided by a licensed doctor of podiatric medicine            $20 per visit
Pregnancy and Maternity Care Benefits
All necessary Inpatient Hospital Services for normal delivery, Cesarean section   $250 per admission plus 20%
and complications of pregnancy
Prenatal and postnatal Physician office visits, including prenatal diagnosis of   You pay nothing
genetic disorders of the fetus by means of diagnostic procedures in cases of
high-risk pregnancy
Note: Routine newborn circumcision is only covered as described in the Cov-
ered Services section. When covered, Services will pay as any other surgery as
noted in this Summary.
Preventive Health Benefits13
Annual mammography, Papanicolaou test, or cervical cancer and human papil-        You pay nothing
lomavirus virus (HPV) screening
Annual routine physical examination office visit                                  You pay nothing
Annual Vision and hearing screening                                               You pay nothing
Colorectal cancer screening                                                       You pay nothing
Osteoporosis screening                                                            You pay nothing
Routine laboratory Services                                                       You pay nothing
Well Baby Office visits                                                           You pay nothing
Well Baby Routine laboratory Services and immunizations                           You pay nothing
Well Baby Vision and hearing screening                                            You pay nothing
Professional (Physician) Benefits
Inpatient Physician Benefits                                                      You pay nothing
Mammography and Papanicolaou test                                                 $20 per visit
Physician home visits                                                             $50 per visit
Physician office visits                                                           $20 per visit
Services with the office visit                                                    $20 per visit
Prosthetic Appliances Benefits
Office visits                                                                     $20 per visit
Prosthetic equipment and devices (except those provided to restore and achieve    You pay nothing
symmetry incident to a mastectomy, which are covered under Ambulatory Sur-
gery Center Benefits, Hospital Benefits (Facility Services), and Professional
(Physician) Benefits in the Principal Benefits and Coverages (Covered Services)
section, and specified devices following a laryngectomy, which are covered
under Physician Services surgical Benefits)
Radiological Procedures Benefits (requiring prior authorization)
Outpatient, non-emergency radiological procedures including CT scans, MRIs,       You pay nothing
MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine
Note: The Claims Administrator requires prior authorization for all these Ser-
vices.




                                                            10
                                    Benefit                                                 Member Copayment3
Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy)
Rehabilitation Services by a physical, occupational, or respiratory therapist in
the following settings:
Office location                                                                       $20 per visit6
Outpatient department of a Hospital                                                   $20 per visit6
Note: Outpatient Rehabilitation Services are limited to a combined Benefit
maximum with chiropractic Services of 26 visits per Member per Calendar
Year.
Rehabilitation unit of a Hospital for Medically Necessary days                        $250 per admission plus 20%
In an Inpatient facility, this Copayment is billed as part of Inpatient Hospital
Services
Skilled Nursing Facility Rehabilitation unit for Medically Necessary days             20%
Skilled Nursing Facility Benefits
Services by a free-standing Skilled Nursing Facility11                                20%
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 per visit6
Outpatient department of a Hospital                                                   $20 per visit6
Rehabilitation unit of a Hospital for Medically Necessary days                        $250 per admission plus 20%
Inpatient facility, this Copayment is billed as part of Inpatient Hospital Services
In the Skilled Nursing Facility Rehabilitation unit for Medically Necessary days      20%
Transplant Benefits – Cornea, Kidney or Skin
Organ Transplants for transplant of a cornea, kidney or skin
   Hospital Services                                                                  $250 per admission plus 20%
   Professional (Physician) Services                                                  You pay nothing
Special Transplant Benefits14 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 com-
bination, and Services to obtain the human transplant material
Transplant Benefits – Special
Note: The Claims Administrator requires prior written authorization 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.
   Facility Services in a Special Transplant Facility                                 $250 per admission plus 20%
   Professional (Physician) Services                                                  You pay nothing




                                                               11
Summary of Benefits
Footnotes
1
     All Benefits must be provided by Preferred Providers, except in an emergency.
2
     There is no Calendar Year Deductible (Medical Plan Deductible on Covered Services.
3
     The following are not included in the maximum Calendar Year Copayment amount:
          Acupuncture Benefits;
          Additional and Reduced Payments under the Benefits Management Program;
          Allergy testing and treatment;
          Ambulance Services;
          Charges in excess of specified benefit maximums;
          Chiropractic Benefits;
          Diabetes self-management training;
          Emergency Room Facility Services;
          Family Planning counseling, IUDs including insertion and removal and injectable contraceptives by a Physician;
          Preferred Physician office and home visits: However, covered Services received during or in connection with a Pre-
          ferred Physician office or home visit accrue to the maximum Calendar Year Copayment amount.
     Note: Copayments and charges for Services not accruing to the Maximum Calendar Year Copayment Responsibility con-
     tinue to be the Member’s responsibility after the Calendar Year Copayment maximum is reached.
4
     Unless otherwise specified, Copayments are calculated based on the Allowable Amount.
5
     The Member’s maximum lifetime Benefit payment amount is determined by totaling all covered Benefits provided to you
     whether you are a Participant or a Dependent while covered under this Plan, or while covered under any prior or subse-
     quent health plan with the Claims Administrator or any of its affiliated companies. Benefits in excess of this amount are
     not covered under this Plan.
6
     If billed by your provider, you will also be responsible for an office visit Copayment.
7
     Prior authorization by the Claims Administrator is required for all dialysis Services.
8
     This Copayment is in addition to the office visit Copayment.
9
     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.
10
     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.
11
     All Inpatient Mental Health Services must be prior authorized by the Claims Administrator.
12
     This Copayment includes both Outpatient facility and Professional (Physician) Services.
13
     If Preventive Care Services are provided in a Preferred or Participating facility or in an Ambulatory Surgery Center, you
     may be responsible for an additional and separate Copayment. See the Ambulatory Surgery Center Benefits and Hospital
     Benefits (Facility Services) sections in the Summary of Benefits for information on Copayments.
14
     Special Transplant Benefits are limited to the procedures listed in the Covered Services section. See the Special Trans-
     plant Benefits Covered Services section for information on Services and requirements.




                                                               12
INTRODUCTION                                                           1.   You or your Physician must obtain the Claims Admin-
                                                                            istrator approval at least 5 working days before Hospi-
The Claims Administrator EPO Plan is specifically de-                       tal or Skilled Nursing Facility admissions for all non-
signed for you to use Claims Administrator Preferred Pro-                   Emergency Inpatient Hospital or Skilled Nursing Facil-
viders. You can control your out-of-pocket costs by care-                   ity Services. (See the “Preferred Providers” section for
fully choosing the providers from whom you receive cov-                     information.)
ered services. The Claims Administrator has a statewide
network of Physician Members and contracted hospitals                  2.   You or your Physician must notify the Claims Admin-
known as Preferred Providers. Many other health care profes-                istrator within 24 hours or by the end of the first busi-
sionals, including optometrists, podiatrists and home health                ness day following emergency admissions, or as soon
care agencies, are also Preferred Providers.                                as it is reasonably possible to do so.

                       IMPORTANT                                       3.   You or your Physician must obtain prior authorization
                                                                            in order to determine if contemplated services are cov-
All covered services, except for emergency and urgent care                  ered. See “Prior Authorization” in the “Benefits Man-
services, must be provided by Preferred Providers. No                       agement Program” section for a listing of Services re-
Benefits are provided when you receive services from a                      quiring prior authorization.
Non-Preferred Provider, except for Medically Necessary
Covered Services received for emergency or urgent care. If             Failure to meet these responsibilities may result in your in-
a Preferred Provider refers you to a Non-Preferred Provider,           curring a substantial financial liability. Some Services may
you are responsible for the total amount billed by the Non-            not be covered unless prior review and other requirements
Preferred Provider (billed charges).                                   are met.

To determine whether a provider is a Preferred Provider,               Note: The Claims Administrator will render a decision on
consult the Preferred Provider Directory. You may also                 all requests for prior authorization within 5 business days
verify this information by accessing the Claims Administra-            from receipt of the request. The treating provider will be
tor’s Internet site located at http://www.blueshieldca.com or          notified of the decision within 24 hours followed by written
by calling Customer Service at the telephone number shown              notice to the provider and Participant within 2 business
on the last page of this booklet. You can only choose pro-             days of the decision. For urgent services in situations in
viders from this list. Note: A Preferred Provider’s status             which the routine decision making process might seriously
may change. It is your obligation to verify whether the Phy-           jeopardize the life or health of a Member or when the
sician, Hospital or Alternate Care Services provider you               Member is experiencing severe pain, the Claims Adminis-
choose is a Preferred Provider, in case there have been any            trator will respond as soon as possible to accommodate the
changes since your Preferred Provider Directory was pub-               Member’s condition not to exceed 72 hours from receipt of
lished.                                                                the request.

If you have questions about your Benefits, contact the                 PLEASE READ THE FOLLOWING INFORMATION SO
Claims Administrator before Hospital or medical Services               YOU WILL KNOW FROM WHOM OR WHAT GROUP
are received.                                                          OF PROVIDERS HEALTH CARE MAY BE OBTAINED.

This Plan is designed to reduce the cost of health care to you,        PREFERRED PROVIDERS
the Participant. In order to reduce your costs, much greater
responsibility is placed on you.                                       The Claims Administrator EPO Medical Plan is specifically
                                                                       designed for you to use the Claims Administrator Preferred
You should read your ASO Benefit Booklet carefully.                    Providers. Preferred Providers include certain Physicians,
Your booklet tells you which services are covered by your              Hospitals, Alternate Care Services Providers, and other
health Plan and which are excluded. It also lists your Co-             Providers. Preferred Providers are listed in the Preferred
payment and deductible responsibilities.                               Provider directories. All Claims Administrator Physician
When you need health care, present your Claims Adminis-                Members are Preferred Providers. So are selected Hospitals
trator ID card to your Physician, Hospital, or other licensed          in your community. Many other healthcare professionals,
healthcare provider. Your ID card has your Participant and             including dentists, podiatrists, optometrists, audiologists,
group numbers on it. Be sure to include these numbers on               licensed clinical psychologists and licensed marriage and
all claims you submit to the Claims Administrator.                     family therapists are also Preferred Providers. They are all
                                                                       listed in your Preferred Provider Directories.
In order to receive Benefits, you should assure that your
provider is a Preferred Provider (see the “Preferred Provid-           To determine whether a provider is a Preferred Provider,
ers” section).                                                         consult the Preferred Provider Directory. You may also
                                                                       verify this information by accessing the Claims Administra-
You are responsible for following the provisions shown in              tor’s Internet site located at http://www.blueshieldca.com or
the “Benefits Management Program” section of this book-                by calling Customer Service at the telephone number shown
let, including:                                                        on the last page of this booklet. Note: A Preferred Pro-
                                                                       vider’s status may change. It is your obligation to verify

                                                                  13
whether the Physician, Hospital or Alternate Care Services            FINANCIAL RESPONSIBILITY FOR CONTINUITY OF
provider you choose is a Preferred Provider, in case there
have been any changes since your Preferred Provider Direc-
                                                                      CARE SERVICES
tory was published.                                                   If a Member is entitled to receive Services from a termi-
                                                                      nated provider under the preceding Continuity of Care pro-
Preferred Providers agree to accept the Claims Administra-
                                                                      vision, the responsibility of the Member to that provider for
tor's payment, plus your payment of any applicable De-
                                                                      Services rendered under the Continuity of Care provisions
ductibles, Copayments, or amounts in excess of specified
                                                                      shall be no greater than for the same Services rendered by a
Benefit maximums, as payment in full for covered Services,
                                                                      Preferred Provider in the same geographic area.
except as provided under the Exception for Other Coverage
provision and the Reductions section regarding Third Party
Liability.                                                            ELIGIBILITY
You are not responsible to Participating and Preferred Pro-           If you are an Employee, you are eligible for coverage as a
viders for payment for covered Services, except for the De-           Participant the day following the date you complete the
ductibles, Copayments, and amounts in excess of specified             waiting period established by your Employer. Your spouse
Benefit maximums, and except as provided under the Ex-                or Domestic Partner and all your Dependent children are
ception for Other Coverage provision.                                 eligible at the same time.
Providers do not receive financial incentives or bonuses              When you decline coverage for yourself or your Depend-
from the Claims Administrator.                                        ents during the initial enrollment period and later request
                                                                      enrollment, you and your Dependents will be considered to
If you go to a Non-Preferred Provider, you are responsible
                                                                      be Late Enrollees. When Late Enrollees decline enrollment
for the total amount billed by the Non-Preferred Provider
                                                                      during the initial enrollment period, they will be eligible the
(billed charges), except for Medically Necessary Covered
                                                                      earlier of 12 months from the date of the request for en-
Services received for emergency or urgent care. It is there-
                                                                      rollment or at the Employer’s next Open Enrollment Period.
fore to your advantage to obtain medical and Hospital Services
                                                                      The Claims Administrator will not consider applications for
from Preferred Providers.
                                                                      earlier effective dates.
Payment for Emergency Services rendered by a Physician
                                                                      You and your Dependents will not be considered to be Late
or Hospital who is not a Preferred Provider will be based on
                                                                      Enrollees if either you or your Dependents lose coverage
the Allowable Amount but will be paid at the Preferred
                                                                      under a previous employer’s health plan and you apply for
level of Benefits. You are responsible for notifying the
                                                                      coverage under this Plan within 31 days of the date of loss of
Claims Administrator within 24 hours, or by the end of the
                                                                      coverage. You will be required to furnish the Claims Ad-
first business day following emergency admission at a Non-
                                                                      ministrator written proof of the loss of coverage.
Preferred Hospital, or as soon as it is reasonably possible to
do so.                                                                Newborn infants of the Participant, spouse, or his or her
                                                                      Domestic Partner will be eligible immediately after birth for
Directories of Preferred Providers located in your area have
                                                                      the first 31 days. A child placed for adoption will be eligi-
been provided to you. Extra copies are available from the
                                                                      ble immediately upon the date the Participant, spouse or
Claims Administrator. If you do not have the directories,
                                                                      Domestic Partner has the right to control the child’s health
please contact the Claims Administrator immediately and
                                                                      care. Enrollment requests for children who have been
request them at the telephone number listed on the last page
                                                                      placed for adoption must be accompanied by evidence of
of this booklet.
                                                                      the Participant’s, spouse’s or Domestic Partner’s right to
                                                                      control the child’s health care. Evidence of such control
CONTINUITY OF CARE BY A TERMINATED                                    includes a health facility minor release report, a medical
PROVIDER                                                              authorization form or a relinquishment form. In order to
Members who are being treated for acute conditions, seri-             have coverage continue beyond the first 31 days without
ous chronic conditions, pregnancies (including immediate              lapse, an application must be submitted to and received by
postpartum care), or terminal illness; or who are children            the Claims Administrator within 31 days from the date of
from birth to 36 months of age; or who have received au-              birth or placement for adoption of such Dependent.
thorization from a now-terminated provider for surgery or             A child acquired by legal guardianship will be eligible on
another procedure as part of a documented course of treat-            the date of the court ordered guardianship, if an application
ment can request completion of care in certain situations             is submitted within 31 days of becoming eligible.
with a provider who is leaving the Claims Administrator
provider network. Contact Customer Service to receive                 You may add newly acquired Dependents and yourself to
information regarding eligibility criteria and the policy and         the Plan by submitting an application within 31 days from
procedure for requesting continuity of care from a termi-             the date of acquisition of the Dependent:
nated provider.                                                       1.   to continue coverage of a newborn or child placed for
                                                                           adoption;


                                                                 14
2.   to add a spouse after marriage, or add a Domestic Part-          If you or your Dependent is a Late Enrollee, your coverage
     ner after establishing a domestic partnership;                   will become effective the earlier of 12 months from the date
                                                                      you made a written request for coverage or at the Em-
3.   to add yourself and spouse following the birth of a
                                                                      ployer’s next Open Enrollment Period. The Claims Admin-
     newborn or placement of a child for adoption;
                                                                      istrator will not consider applications for earlier effective
4.   to add yourself and spouse after marriage;                       dates.
5.   to add yourself and your newborn or child placed for             If you declined coverage for yourself and your Dependents
     adoption, following birth or placement for adoption.             during the initial enrollment period because you or your
                                                                      Dependents were covered under another employer health
A completed health statement may be required with the                 plan, and you or your Dependents subsequently lost cover-
application. Coverage is never automatic; an application is           age under that plan, you will not be considered a Late En-
always required.                                                      rollee. Coverage for you and your Dependents under this
If both partners in a marriage or domestic partnership are            Plan will become effective on the date of loss of coverage,
both eligible to be Participants, children may be eligible and        provided you enroll in this Plan within 31 days from the
may be enrolled as a Dependent of either parent, but not              date of loss of coverage. You will be required to furnish
both.                                                                 the Claims Administrator written evidence of loss of cover-
                                                                      age.
Enrolled Dependent children who would normally lose their
eligibility under this Plan solely because of age, but who            If you declined enrollment during the initial enrollment
are incapable of self-sustaining employment by reason of a            period and subsequently acquire Dependents as a result of
physically or mentally disabling injury, illness, or condi-           marriage, establishment of domestic partnership, birth, or
tion, may have their eligibility extended under the follow-           placement for adoption, you may request enrollment for
ing conditions: (1) the child must be chiefly dependent               yourself and your Dependents within 31 days. The effec-
upon the Employee for support and maintenance, and (2)                tive date of enrollment for both you and your Dependents
the Employee must submit a Physician’s written certifica-             will depend on how you acquire your Dependent(s):
tion of such disabling condition. The Claims Administrator
                                                                      1.   For marriage or domestic partnership, the effective date
or the Employer will notify you at least 90 days prior to the              will be the first day of the first month following receipt
date the Dependent child would otherwise lose eligibility.                 of your request for enrollment;
You must submit the Physician’s written certification
within 60 days of the request for such information by the             2.   For birth, the effective date will be the date of birth;
Employer or by the Plan. Proof of continuing disability and
                                                                      3.   For a child placed for adoption, the effective date will
dependency must be submitted by the Employee as re-
                                                                           be the date the Participant, spouse, or Domestic Partner
quested by the Claims Administrator but not more fre-
                                                                           has the right to control the child’s health care.
quently than 2 years after the initial certification and then
annually thereafter.                                                  Once each Calendar Year, your Employer may designate a
                                                                      time period as an annual Open Enrollment Period. During
The Employer must meet specified Employer eligibility,
                                                                      that time period, you and your Dependents may transfer
participation and contribution requirements to be eligible
                                                                      from another health plan sponsored by your Employer to
for this group Plan. See your Employer for further informa-
                                                                      the Preferred Plan. A completed enrollment form must be
tion.
                                                                      forwarded to the Claims Administrator within the Open
Subject to the requirements described under the Continua-             Enrollment Period. Enrollment becomes effective on the
tion of Group Coverage provision in this booklet, if appli-           anniversary date of this Plan following the annual Open
cable, an Employee and his or her Dependents will be eligi-           Enrollment Period.
ble to continue group coverage under this Plan when cover-
                                                                      Any individual who becomes eligible at a time other than
age would otherwise terminate.
                                                                      during the annual Open Enrollment Period (e.g., newborn,
                                                                      child placed for adoption, child acquired by legal guardian-
EFFECTIVE DATE OF COVERAGE                                            ship, new spouse or Domestic Partner, newly hired or
                                                                      newly transferred Employees) must complete an enrollment
Coverage will become effective for Employees and De-
                                                                      form within 31 days of becoming eligible.
pendents who enroll during the initial enrollment period at
12:01 a.m. Pacific Time on the eligibility date established           Coverage for a newborn child will become effective on the
by your Employer.                                                     date of birth. Coverage for a child placed for adoption will
                                                                      become effective on the date the Participant, spouse or Do-
If, during the initial enrollment period, you have included
                                                                      mestic Partner has the right to control the child’s health
your eligible Dependents on your application to the Claims
                                                                      care, following submission of evidence of such control (a
Administrator, their coverage will be effective on the same
                                                                      health facility minor release report, a medical authorization
date as yours. If application is made for Dependent cover-
                                                                      form or a relinquishment form). In order to have coverage
age within 31 days after you become eligible, their effective
                                                                      continue beyond the first 31 days without lapse, a written
date of coverage will be the same as yours.
                                                                      application must be submitted to and received by the

                                                                 15
Claims Administrator within 31 days. A Dependent spouse               the day immediately following the completion of the annual
becomes eligible on the date of marriage. A Domestic                  Open Enrollment Period.
Partner becomes eligible on the date a domestic partnership
is established as set forth in the Definitions section of this        SPECIAL ENROLLMENT EVENT
booklet. A child acquired by legal guardianship will be
eligible on the date of the court ordered guardianship.               If you or your Dependent request enrollment after the first
                                                                      period in which you or your Dependent were eligible to
If a court has ordered that you provide coverage for your             enroll but during a Special Enrollment Event due to a fam-
spouse, Domestic Partner or Dependent child under your                ily status change (newborn, child placed for adoption, child
health benefit Plan, their coverage will become effective             acquired by legal guardianship, new spouse or Domestic
within 31 days of presentation of a court order by the dis-           Partner, newly hired or newly transferred Employees), you
trict attorney, or upon presentation of a court order or re-          or your Dependent will be a special enrollee and will not be
quest by a custodial party, as described in Section 3751.5 of         considered a late enrollee.
the Family Code.
                                                                      If the Employer offers different Benefit options, a Benefit
If you or your Dependents voluntarily discontinued cover-             option transfer may also be made on any contribution due
age under this Plan and later request reinstatement, you or           date if your request is due to a special enrollment event and
your Dependents will be covered the earlier of 12 months              you complete the appropriate enrollment form within the
from the date of request for reinstatement or at the Em-              time specified for a special enrollment event due to a family
ployer’s next Open Enrollment Period.                                 status change (newborn, child placed for adoption, child
If this Plan provides Benefits within 60 days of the date of          acquired by legal guardianship, new spouse or Domestic
discontinuance of the previous group health plan that was in          Partner, newly hired or newly transferred Employees).
effect with your Employer, you and all your Dependents                If a request for contributory coverage is made more than 31
who were validly covered under the previous group health              days after the date an individual is eligible but during a spe-
plan on the date of discontinuance, will be eligible under            cial enrollment event due to a family status change, cover-
this Plan.                                                            age for such individual will become effective as described
                                                                      within in this section.
MEDICAL CARE BENEFITS
The individual’s coverage will be effective as described in           EFFECTIVE DATE FOR LATE ENROLLEES
this booklet:                                                         If a late enrollee requests coverage other than during an
                                                                      annual Open Enrollment Period or Special Enrollment Pe-
ANNUAL OPEN ENROLLMENT                                                riod, the effective date of coverage for the late enrollee will
                                                                      be the next plan anniversary date, provided on such date:
An annual Open Enrollment Period will be available for
any Member or Dependent who failed to enroll:                         •   the Member continues to meet the Plan’s definition of
                                                                          Member; and
•   during the first period in which he or she was eligible
    to enroll, or during any subsequent Special Enrollment            •   for Dependent coverage, the Dependents continue to
    Period; or                                                            meet the Plan’s definition of Dependent.
•   during any previous annual Open Enrollment Period; or
                                                                      RENEWAL OF PLAN
•   within 31 days after the termination date, if the indi-
    vidual was previously covered under the Plan but                  The Claims Administrator will offer to renew the
    elected to terminate the coverage.                                Plan except in the following instances:
To qualify for enrollment during the annual Open Enroll-              1. non-payment of fees (see “Termination of
ment Period, the Member or Dependent:
                                                                         Benefits”);
•   must meet the eligibility requirements described in the
    Plan, including satisfaction of any applicable waiting            2. fraud, misrepresentations or omissions;
    period; and                                                       3. failure to comply with the Claims Administra-
•   may not be covered under an alternate medical expense                tor's applicable eligibility, participation or con-
    coverage offered by the Employer, unless the annual                  tribution rules;
    Open Enrollment Period happens to coincide with a
    separate Open Enrollment Period established for cov-              4. termination of plan type by the Claims Ad-
    erage election.                                                      ministrator;
The effective date for any qualified individual requesting            5. Employer moves out of the service area;
coverage during the annual Open Enrollment Period will be


                                                                 16
6. association membership ceases.                                     and information about minor illnesses and injuries, chronic
                                                                      conditions, fitness, nutrition and other health related topics.
All groups will renew subject to the above.
                                                                      THE CLAIMS ADMINISTRATOR ONLINE
SERVICES FOR EMERGENCY CARE
                                                                      The Claims Administrator’s Internet site is located at
The Benefits of this Plan will be provided for covered Ser-           http://www.blueshieldca.com. Members with Internet ac-
vices received anywhere in the world for the emergency                cess and a Web browser may view and download healthcare
care of an illness or injury.                                         information.
Members who reasonably believe that they have an emer-
gency medical condition which requires an emergency re-               BENEFITS MANAGEMENT PROGRAM
sponse are encouraged to appropriately use the “911” emer-
                                                                      The Claims Administrator has established the Benefits
gency response system where available.
                                                                      Management Program to assist you, your Dependents, or
                                                                      provider in identifying the most appropriate and cost-
SECOND MEDICAL OPINION POLICY                                         effective course of treatment for which certain Benefits will
                                                                      be provided under this health Plan and for determining
If you have a question about your diagnosis, or believe that
                                                                      whether the services are Medically Necessary. However,
additional information concerning your condition would be
                                                                      you, your Dependents and provider make the final decision
helpful in determining the most appropriate plan of treat-
                                                                      concerning treatment. The Benefits Management Program
ment, you may make an appointment with another Physi-
                                                                      includes: prior authorization review for certain services;
cian for a second medical opinion. Your attending Physi-
                                                                      emergency admission notification; Hospital Inpatient re-
cian may also offer to refer you to another Physician for a
                                                                      view, discharge planning, and case management if deter-
second opinion.
                                                                      mined to be applicable and appropriate by the Claims Ad-
Remember that the second opinion visit is subject to all              ministrator.
Plan Benefit limitations and exclusions.
                                                                      Certain portions of the Benefits Management Program also
                                                                      contain Additional and Reduced Payment requirements for
HEALTH EDUCATION AND                                                  either not contacting the Claims Administrator or not fol-
HEALTH PROMOTION SERVICES                                             lowing the Claims Administrator’s recommendations. Fail-
                                                                      ure to contact the Plan for authorization of services listed in
Health education and health promotion Services provided               the sections below or failure to follow the Plan’s recom-
by the Claims Administrator’s Center for Health Improve-              mendations may result in reduced payment or non-payment
ment offer a variety of wellness resources including, but not         if the Claims Administrator determines the service was not
limited to: a Participant newsletter and a prenatal health            a covered Service. Please read the following sections thor-
education program.                                                    oughly so you understand your responsibilities in reference
                                                                      to the Benefits Management Program. Remember that all
RETAIL-BASED HEALTH CLINICS                                           provisions of the Benefits Management Program also apply
Retail-based health clinics are Outpatient facilities, usually        to your Dependents.
attached or adjacent to retail stores, pharmacies, etc., which
                                                                      The Claims Administrator requires prior authorization for
provide limited, basic medical treatment for minor health
                                                                      selected Inpatient and Outpatient services, supplies and
issues. They are staffed by nurse practitioners under the
                                                                      Durable Medical Equipment; PKU related formulas and
direction of a Physician and offer services on a walk-in
                                                                      Special Food Products; admission into an approved Hos-
basis. Covered Services received from retail-based health
                                                                      pice Program; and certain radiology procedures. Pread-
clinics will be paid on the same basis and at the same Bene-
                                                                      mission review is required for all Inpatient Hospital and
fit levels as other covered Services shown in the Summary
                                                                      Skilled Nursing Facility services (except for Emergency
of Benefits. Retail-based health clinics may be found in the
                                                                      Services*).
Preferred Provider Directory or the Online Physician Direc-
tory located at http://www.blueshieldca.com.                          *See the paragraph entitled Emergency Admission Notifi-
                                                                      cation later in this section for notification requirements.
NURSEHELP 24/7                                                        By obtaining prior authorization for certain services prior to
                                                                      receiving services, you and your provider can verify: (1) If
The NurseHelp 24/7 program provides Members with no
                                                                      the Claims Administrator considers the proposed treatment
charge, confidential, unlimited telephone support for infor-
                                                                      Medically Necessary, (2) if Plan Benefits will be provided
mation and consultations. Members may obtain this service
                                                                      for the proposed treatment, and (3) if the proposed setting is
by calling a 24-hour, toll-free telephone number. There is
                                                                      the most appropriate as determined by the Claims Adminis-
no charge for this service.
                                                                      trator. You and your provider may be informed about Ser-
Members may call a registered nurse toll free via 1-877-              vices that could be performed on an Outpatient basis in a
304-0504, 24 hours a day, to receive confidential advice              Hospital or Outpatient Facility.

                                                                 17
PRIOR AUTHORIZATION                                                    5.   Surgery Services which may be considered to be Cos-
                                                                            metic in nature rather than Reconstructive (e.g., eyelid
For services listed in the section below, you or your pro-                  surgery, rhinoplasty, abdominoplasty, or breast reduc-
vider can determine before the service is provided whether                  tion) and those Reconstructive Surgeries which may re-
a procedure or treatment program is a Covered Service and                   sult in only minimal improvement in function or ap-
may also receive a recommendation for an alternative Ser-                   pearance. Reconstructive Surgery is limited to Medi-
vice. Failure to contact the Claims Administrator as de-                    cally Necessary surgeries and procedures as described
scribed below or failure to follow the recommendations of                   in Ambulatory Surgery Center Benefits, Hospital Bene-
the Claims Administrator for Covered Services will result                   fits (Facility Services), and Professional (Physician)
in a reduced payment per procedure as described in the sec-                 Benefits in the Covered Services section.
tion entitled Additional and Reduced Payments for Failure
to Use the Benefits Management Program.                                6.   Arthroscopic surgery of the temporomandibular joint
                                                                            (TMJ) Services.
For Services other than those listed in the sections below,
you, your Dependents or provider should consult the Prin-              7.   Dialysis Services as specified under the Dialysis Center
cipal Benefits and Coverages (Covered Services) section of                  Benefits and Hospital Benefits (Facility Services) in
this booklet to determine whether a service is covered.                     the Covered Services section.

You or your Physician must call 1-800-343-1691 for prior               Failure to obtain prior authorization or to follow the rec-
authorization for the services listed in this section except           ommendations of the Claims Administrator for:
for the Outpatient radiological procedures described in item                injectable drugs administered in the Physician office
9. below. For prior authorization for these radiological pro-               setting,
cedures, you or your Physician must call 1-888-642-2583.
                                                                            Durable Medical Equipment Benefits,
The Claims Administrator requires prior authorization for
the following services:                                                     cosmetic surgery Services,

1.   Admission into an approved Hospice Program as speci-                   arthroscopic surgery of the TMJ services, and
     fied under Hospice Program Benefits in the Covered                     dialysis Services
     Services section.
                                                                       as described above may result in non-payment of services
2.   Clinical Trial for Cancer Benefits.                               by the Claims Administrator.
     Members who have been accepted into an approved                   8.   PKU Related Formulas and Special Food Products
     clinical trial for cancer as defined under the Covered                 Benefits.
     Services section must obtain prior authorization from
     the Claims Administrator in order for the routine pa-             9.   The following radiological procedures when performed
     tient care delivered in a clinical trial to be covered.                in an Outpatient setting on a non-emergency basis:

Failure to obtain prior authorization or to follow the rec-                 CT (Computerized Tomography) scans, MRIs (Mag-
ommendations of the Claims Administrator for Hospice                        netic Resonance Imaging), MRAs (Magnetic Reso-
Program Benefits and Clinical Trial for Cancer Benefits                     nance Angiography), PET (Positron Emission Tomo-
above will result in non-payment of services by the Claims                  graphy) scans, and any cardiac diagnostic procedure
Administrator.                                                              utilizing Nuclear Medicine.

3.   Select injectable drugs administered in the Physician                  Prior authorization is not required for these radiological
     office setting.*                                                       services when obtained outside of California. See the
                                                                            “Out-Of-Area Program: The BlueCard Program” sec-
     *Prior authorization is based on Medical Necessity,                    tion of this booklet for an explanation of how payment
     appropriateness of therapy, or when effective alterna-                 is made for out of state services.
     tives are available.
                                                                       10. Special Transplant Benefits as specified under Special
     Note: Your Physician must obtain prior authorization                  Transplant Benefits in the Covered Services section).
     for select injectable drugs administered in the Physi-
     cian’s office. Failure to obtain prior authorization or to        11. All bariatric surgery.
     follow the recommendations of the Claims Administra-              12. Outpatient Speech Therapy Services as specified under
     tor for select injectable drugs may result in non-                    Speech Therapy Benefits in the Covered Services sec-
     payment by the Claims Administrator if the service is                 tion.
     determined not to be a covered Service.
                                                                       13. Hospital and Skilled Nursing Facility admissions (see
4.   Durable Medical Equipment Benefits, including but not                 the subsequent Hospital and Skilled Nursing Facility
     limited to motorized wheelchairs, insulin infusion                    Admissions section for more information).
     pumps, and CPAP (Continuous Positive Air Pressure)
     machines.


                                                                  18
Failure to obtain prior authorization or to follow the rec-          6.   Heart catheterization;
ommendations of the Claims Administrator for:
                                                                     7.   Diagnostic bronchoscopy;
     PKU Related Formulas and Special Food Products
                                                                     8.   Creation of arterial venous shunts (for hemodialysis).
     Benefits,
                                                                     Failure to contact the Claims Administrator as described or
     Outpatient radiological procedures as specified above,
                                                                     failure to follow the recommendations of the Claims Ad-
     Special Transplant Benefits,                                    ministrator will result in an additional payment per admis-
                                                                     sion as described in the Additional and Reduced Payments
     all bariatric surgery,
                                                                     for Failure to Use the Benefits Management Program sec-
     Outpatient Speech Therapy Services, and                         tion or may result in reduction or non-payment if the
                                                                     Claims Administrator determines that the admission is not a
     Hospital and Skilled Nursing Facility admissions.               covered Service.*
as described above will result in a reduced payment as de-           *Note: For admissions for special transplant Benefits, fail-
scribed in the Additional and Reduced Payments for Failure
                                                                     ure to receive prior authorization in writing and/or failure to
to Use the Benefits Management Program section or may                have the procedure performed at the Claims Administrator
result in non-payment if the Claims Administrator deter-             designated facility will result in non-payment of services by
mines that the service is not a covered Service.
                                                                     the Claims Administrator. See Transplant Benefits under
Other specific services and procedures may require prior             the Covered Services section for details.
authorization as determined by the Claims Administrator.
A list of services and procedures requiring prior authoriza-         EMERGENCY ADMISSION NOTIFICATION
tion can be obtained by your provider by going to
http://www.blueshieldca.com or by calling 1-800-343-1691.            If you are admitted for Emergency Services, the Claims
                                                                     Administrator should receive emergency admission notifi-
                                                                     cation within 24 hours or by the end of the first business
HOSPITAL AND SKILLED NURSING FACILITY                                day following the admission, or as soon as it is reasonably
ADMISSIONS                                                           possible to do so, or you may be responsible for the addi-
Prior authorization must be obtained from the Claims Ad-             tional payment as described under the Additional and Re-
ministrator for all Hospital and Skilled Nursing Facility            duced Payments for Failure to Use the Benefits Manage-
admissions (except for admissions required for Emergency             ment Program section.
Services). Included are hospitalizations for continuing In-
patient Rehabilitation and skilled nursing care, transplants,        HOSPITAL INPATIENT REVIEW
bariatric surgery, and Inpatient Mental Health Services if
                                                                     The Claims Administrator monitors Inpatient stays. The
this health plan provides these benefits.                            stay may be extended or reduced as warranted by your con-
Whenever a Hospital or Skilled Nursing Facility admission            dition, except in situations of maternity admissions for
is recommended by your Physician, you or your Physician              which the length of stay is 48 hours or less for a normal,
must contact the Claims Administrator at 1-800-343-1691              vaginal delivery or 96 hours or less for a Cesarean section
at least 5 business days prior to the admission. However, in         unless the attending Physician, in consultation with the
case of an admission for Emergency Services, the Claims              mother, determines a shorter Hospital length of stay is ade-
Administrator should receive emergency admission notifi-             quate. Also, for mastectomies or mastectomies with lymph
cation within 24 hours or by the end of the first business           node dissections, the length of Hospital stays will be deter-
day following the admission, or as soon as it is reasonably          mined solely by your Physician in consultation with you.
possible to do so. The Claims Administrator will discuss             When a determination is made that the Member no longer
the Benefits available, review the medical information pro-          requires the level of care available only in an Acute Care
vided and may recommend that to obtain the full Benefits             Hospital, written notification is given to you and your Doc-
of this health Plan that the Services be performed on an             tor of Medicine. You will be responsible for any Hospital
Outpatient basis.                                                    charges Incurred beyond 24 hours of receipt of notification.
Examples of procedures that may be recommended to be
performed on an Outpatient basis if medical conditions do
                                                                     DISCHARGE PLANNING
not indicate Inpatient care include:                                 If further care at home or in another facility is appropriate fol-
1.   Biopsy of lymph node, deep axillary;                            lowing discharge from the Hospital, the Claims Administrator
                                                                     will work with the Physician and Hospital discharge planners
2.   Hernia repair, inguinal;                                        to determine whether benefits are available under this Plan to
                                                                     cover such care.
3.   Esophagogastroduodenoscopy with biopsy;
4.   Excision of ganglion;
5.   Repair of tendon;


                                                                19
CASE MANAGEMENT                                                        ment Program notification requirements or recommenda-
                                                                       tions.
The Benefits Management Program may also include case
management, which provides assistance in making the most               2.   Failure to obtain prior authorization or to follow the
efficient use of Plan Benefits. Individual case management                  recommendations of the Claims Administrator for cov-
may also arrange for alternative care benefits in place of                  ered, Medically Necessary enteral formulas and Special
prolonged or repeated hospitalizations, when it is deter-                   Food Products for the treatment of phenylketonuria
mined to be appropriate through the Claims Administrator                    (PKU) will result in a 50% reduction in the amount
review. Such alternative care benefits will be available                    payable by the Claims Administrator after the calcula-
only by mutual consent of all parties and, if approved, will                tion of the Deductible and any applicable Copayments
not exceed the Benefit to which you would otherwise have                    required by this Plan. You will be responsible for the
been entitled under this Plan. The Claims Administrator is                  applicable Deductibles and/or Copayments and the ad-
not obligated to provide the same or similar alternative care               ditional 50% of the charges that are payable under this
benefits to any other person in any other instance. The ap-                 Plan.
proval of alternative benefits will be for a specific period of        3.   Failure to receive prior authorization for the radiologi-
time and will not be construed as a waiver of the Claims                    cal procedures listed in the Benefits Management Pro-
Administrator’s right to thereafter administer this health                  gram section under Prior Authorization or to follow the
Plan in strict accordance with its express terms.                           recommendations of the Claims Administrator will re-
                                                                            sult in non-payment for procedures which are deter-
ADDITIONAL AND REDUCED PAYMENTS                                             mined not to be covered Services.
FOR FAILURE TO USE THE
                                                                       DEDUCTIBLE
BENEFITS MANAGEMENT PROGRAM
For non-Emergency Services, additional payments may be                 CALENDAR YEAR DEDUCTIBLE
required, or payments may be reduced, as described below,              (MEDICAL PLAN DEDUCTIBLE)
when a Participant or Dependent fails to follow the proce-
dures described under the Prior Authorization and Skilled              There is no Calendar Year deductible under this Plan.
Nursing Facility Admissions sections of the Benefits Man-
agement Program. These additional payments will be re-                 MAXIMUM AGGREGATE PAYMENT
quired in addition to any applicable Calendar Year De-
ductible, Copayment and amounts in excess of Benefit dol-              AMOUNT
lar maximums specified and will not be included in the cal-            There is no maximum aggregate payment under this plan;
culation of the Participant’s maximum Calendar Year Co-                however, all specified Benefit maximums do apply.
payment responsibility.
1.   Failure to contact the Claims Administrator as de-                PAYMENT
     scribed under the Prior Authorization of the Benefits
     Management Program or failure to follow the recom-                The Participant Copayment amounts, applicable Deducti-
     mendations of the Claims Administrator will result in             bles, and Copayment maximum amounts for covered Ser-
     an additional payment per Hospital or Skilled Nursing             vices are shown in the Summary of Benefits. The Sum-
     Facility admission as described below or may result in            mary of Benefits also contains information on Benefit and
     reduction or non-payment if the Claims Administrator              Copayment maximums and restrictions.
     determines that the admission is not a covered Service.           Complete benefit descriptions may be found in the Principal
                                                                       Benefits and Coverages (Covered Services) section. Plan
     •   *$250 per Hospital or Skilled Nursing Facility
                                                                       exclusions and limitations may be found in the Principal
         admission.
                                                                       Limitations, Exceptions, Exclusions and Reductions sec-
     •   *$250 per Hospital admission for the diagnosis or             tion.
         treatment of Substance Abuse Conditions if sub-
         stance abuse coverage is selected as an optional              Out-of-Area Program: The BlueCard® Program
         Benefit by your Employer. Note: Inpatient Ser-                Benefits will be provided, according to paragraphs (1.), (2.)
         vices which are Medically Necessary to treat the              and (3.) below, for covered Services received outside of
         acute medical complications of detoxification are             California within the United States. The Claims Adminis-
         covered as part of the medical Benefits and are not           trator calculates the Participant's Copayment either as a
         considered to be treatment of the Substance Abuse             percentage of the Allowable Amount or a dollar copayment,
         Condition itself.                                             as defined in this booklet. When covered Services are re-
Only one $250 additional payment will apply to each Hos-               ceived in another state, the Participant's Copayment will be
pital admission for failure to follow the Benefits Manage-             based on the local Blue Cross and/or Blue Shield plan's
                                                                       arrangement with its providers.


                                                                  20
1.   Covered Services received from a provider who has                 this plan will be provided for covered Services received
     contracted with the local Blue Cross and/or Blue Shield           anywhere in the world for emergency care of an illness or
     plan are paid at the Preferred level. Participants are re-        injury.
     sponsible for the remaining copayment.
                                                                       Care for Covered Urgent Care and Emergency Services
2.   Non-emergency covered Services received from pro-                 Outside the United States
     viders who have not contracted with the local Blue
                                                                       Benefits will also be provided for covered Services received
     Cross and/or Blue Shield plan are not covered. Partici-
                                                                       outside of the United States through the BlueCard World-
     pants are responsible for the entire bill for your medical
                                                                       wide® Network. If you need urgent care while out of the
     care.
                                                                       country, call either the toll-free BlueCard Program Access
3.   Emergency Services received from providers who have               number at 1-800-810-2583 or call collect at
     not contracted with the local Blue Cross and/or Blue              1-804-673-1177, 24 hours a day, seven days a week. In an
     Shield plan are paid at the Preferred level of billed             emergency, go directly to the nearest hospital. If your cov-
     charges, except that services of Physicians and Hospi-            erage requires precertification or prior authorization, you
     tals are paid based on the Allowable Amount. Partici-             should call the Claims Administrator at 1-800-343-1691.
     pants are responsible for the remaining copayment.                For inpatient hospital care at participating hospitals, show
                                                                       your I.D. card to the hospital staff upon arrival. You are
If you do not see a Participating Provider through the Blue-
                                                                       responsible for the usual out-of-pocket expenses (non-
Card Program, you will have to pay for the entire bill for
                                                                       covered charges, Deductibles, and copayments).
your medical care.
                                                                       When you receive services from a physician, you will have
Charges for Services which are not covered, and charges by
                                                                       to pay the doctor and then submit a claim. Also for inpa-
Non-Preferred Providers are the Participant's responsibility
                                                                       tient hospitalization, if you do not use the BlueCard Pro-
and are not included in copayment calculations.
                                                                       gram Worldwide Network, you will have to pay the entire
To receive the maximum benefits of your plan, please fol-              bill for your medical care and submit a claim form (with a
low the procedure below.                                               copy of the bill) to the Claims Administrator.
When you require covered Services while traveling outside              Before traveling abroad, call your local Customer Service
of California:                                                         office for the most current listing of participating Hospitals
                                                                       worldwide or you can go on-line at http://www.bcbs.com
1.   call BlueCard Access® at 1-800-810-BLUE (2583) to
                                                                       and select “Find a Doctor or Hospital”.
     locate Physicians and Hospitals that participate with
     the local Blue Cross and/or Blue Shield plan, or go on-           Calculation of your Deductibles, copayments and maximum
     line at http://www.bcbs.com and select the “Find a                copayment responsibilities under the BlueCard Program:
     Doctor or Hospital” tab; and,
                                                                       When you obtain health care services through the BlueCard
2.   visit the Participating Physician or Hospital and present         Program outside of California, the amount you pay for cov-
     your membership card.                                             ered services is calculated on the lower of:
The Participating Physician or Hospital will verify your               1.   The Allowable Amount for your covered services, or
eligibility and coverage information by calling BlueCard
                                                                       2.   The negotiated price that the local Blue Cross and/or
Eligibility at 1-800-676-BLUE. Once verified and after
                                                                            Blue Shield plan passes on to us.
Services are provided, a claim is submitted electronically
and the Participating Physician or Hospital is paid directly.          Often, this "negotiated price" will consist of a simple dis-
You may be asked to pay for your applicable copayment                  count which reflects the actual price paid by the local Blue
and plan Deductible at the time you receive the service.               Cross and/or Blue Shield plan. But sometimes it is an esti-
                                                                       mated price that factors into the actual price expected set-
You will receive an Explanation of Benefits which will
                                                                       tlements, withholds, any other contingent payment ar-
show your payment responsibility. You are responsible for
                                                                       rangements and non-claims transactions with your health
the copayment and plan Deductible amounts shown in the
                                                                       care provider or with a specified group of providers. The
Explanation of Benefits.
                                                                       negotiated price may also be billed charges reduced to re-
Prior authorization is required for all Inpatient Hospital             flect an average expected savings with your health care
Services and notification is required for Inpatient Emer-              provider or with a specified group of providers. The price
gency Services. Prior authorization is required for selected           that reflects average savings may result in greater variation
Inpatient and Outpatient Services, supplies and durable                (more or less) from the actual price paid than will the esti-
medical equipment. To receive prior authorization from the             mated price. The negotiated price will also be adjusted in
Claims Administrator, the out-of-area provider should call             the future to correct for over- or underestimation of past
1-800-343-1691.                                                        prices. However, the amount you pay is considered a final
                                                                       price.
If you need Emergency Services, you should seek immedi-
ate care from the nearest medical facility. The Benefits of            Statutes in a small number of states may require the local
                                                                       Blue Cross and/or Blue Shield plan to use a basis for calcu-

                                                                  21
lating Participant liability for covered Services that does not        descriptions below, and to the Principal Limitations, Excep-
reflect the entire savings realized, or expected to be real-           tions, Exclusions and Reductions listed in this booklet.
ized, on a particular claim or to add a surcharge. Should
                                                                       The Copayments for covered Services, if applicable, are
any state statutes mandate Participant liability calculation
                                                                       shown on the Summary of Benefits.
methods that differ from the usual BlueCard Program
method noted above or require a surcharge, the Claims                                         IMPORTANT
Administrator would then calculate your liability for any
                                                                       All covered services, except for emergency and urgent ser-
covered health care services in accordance with the appli-
cable state statute in effect at the time you received your            vices, must be rendered by Preferred Providers. No bene-
care.                                                                  fits are provided when you receive services from a Non-
                                                                       Preferred Provider except for Medically Necessary covered
For any other providers, the amount you pay, if not subject            services received for emergency or urgent care. If a Pre-
to a flat dollar copayment, is calculated on the provider’s            ferred Provider refers you to a Non-Preferred Provider, you
Allowable Amount for your covered services.                            are responsible for the total amount billed by the Non-
                                                                       Preferred Provider.
PARTICIPANT’S MAXIMUM CALENDAR YEAR                                    Except as specifically provided herein, Services are covered
COPAYMENT RESPONSIBILITY                                               only when rendered by an individual or entity that is li-
The per Member and per Family maximum Copayment                        censed or certified by the state to provide health care ser-
responsibility each Calendar Year for covered Services ren-            vices and is operating within the scope of that license or
dered by Preferred Providers and Other Providers is shown              certification.
on the Summary of Benefits.
                                                                       ACUPUNCTURE BENEFITS
Once a Member’s maximum responsibility has been met*,
the Plan will pay 100% of the Allowable Amount for that                Benefits are provided for acupuncture treatment by a Doc-
Member’s covered Services for the remainder of that Cal-               tor of Medicine (M.D.) or a certificated acupuncturist up to
endar Year, except as described below. Once the Family                 the per visit dollar maximum shown on the Summary of
maximum responsibility has been met*, the Plan will pay                Benefits.
100% of the Allowable Amount for the Participant’s and all             Benefits are limited to a per Member per Calendar Year
covered Dependents’ covered Services for the remainder of              visit maximum as shown on the Summary of Benefits.
that Calendar Year, except as described below.
Charges for Services which are not covered, charges above              ALLERGY TESTING AND TREATMENT BENEFITS
the Allowable Amount, charges in excess of the amount
covered by the Plan, and reduced payments Incurred under               Benefits are provided for allergy testing and treatment.
the Benefits Management Program are the Participant's re-
sponsibility and are not included in the maximum Calendar              AMBULANCE BENEFITS
Year Copayment responsibility.                                         Benefits are provided for (1) Medically Necessary ambu-
*Note: Certain Services and amounts are not included in                lance Services (surface and air) when used to transport a
the calculation of the maximum Calendar Year Copayment.                Member from place of illness or injury to the closest medi-
These items are shown on the Summary of Benefits.                      cal facility where appropriate treatment can be received, or
                                                                       (2) Medically Necessary ambulance transportation from one
Charges for these items may cause a Participant’s payment              medical facility to another.
responsibility to exceed the maximums.
Copayments and charges for Services not accruing to the                AMBULATORY SURGERY CENTER BENEFITS
Participant’s maximum Calendar Year Copayment respon-
                                                                       Ambulatory surgery Services means surgery which does not
sibility continue to be the Participant’s responsibility after
                                                                       require admission to a Hospital (or similar facility) as a
the Calendar Year Copayment maximum is reached.
                                                                       registered bed patient.

PRINCIPAL BENEFITS AND COVERAGES                                       Outpatient routine newborn circumcisions are covered
                                                                       when performed in an ambulatory surgery center. For the
(COVERED SERVICES)                                                     purposes of this Benefit, routine newborn circumcisions are
Benefits are provided for the following Medically Neces-               circumcisions performed within 31 days of birth unrelated
sary covered Services, subject to applicable Deductibles,              to illness or injury. Routine circumcisions after this time
Copayments and charges in excess of Benefit maximums,                  period are covered for sick babies when authorized by the
Preferred Provider provisions and Benefits Management                  Claims Administrator.
Program provisions. Coverage for these Services is subject             Outpatient Services including general anesthesia and asso-
to all terms, conditions, limitations and exclusions of the            ciated facility charges in connection with dental procedures
Plan, to any conditions or limitations set forth in the benefit        are covered when performed in an ambulatory surgery cen-


                                                                  22
ter because of an underlying medical condition or clinical           Benefits are limited to a combined per Member per Calen-
status and the Member is under the age of seven or devel-            dar Year visit maximum with Rehabilitation Services as
opmentally disabled regardless of age or when the Mem-               shown on the Summary of Benefits.
ber’s health is compromised and for whom general anesthe-
                                                                     Covered lab and X-ray Services provided in conjunction
sia is Medically Necessary regardless of age. This benefit
                                                                     with this Benefit have an additional Copayment as shown
excludes dental procedures and services of a dentist or oral
                                                                     under the Outpatient X-ray, Pathology and Laboratory
surgeon.
                                                                     Benefits section.
Note: Reconstructive Surgery and associated covered Ser-
vices are only covered when determined by the Claims                 CLINICAL TRIAL FOR CANCER BENEFITS
Administrator to be Medically Necessary and only to cor-
rect or repair abnormal structures of the body and which             Benefits are provided for routine patient care for Members
result in more than a minimal improvement in function or             who have been accepted into an approved clinical trial for
appearance. In accordance with the Women's Health &                  cancer when prior authorized by the Claims Administrator,
Cancer Rights Act, Reconstructive Surgery on either breast           and:
provided to restore and achieve symmetry incident to a               1.   the clinical trial has a therapeutic intent and the Mem-
mastectomy including treatment of physical complications                  ber’s treating Physician determines that participation in
of a mastectomy and lymphedemas is covered. For cover-                    the clinical trial has a meaningful potential to benefit
age of prosthetic devices incident to a mastectomy, see Re-               the Member with a therapeutic intent; and
constructive Surgery under Professional (Physician) Bene-
fits. Any such Services must be received while the plan is           2.   the Member’s treating Physician recommends partici-
in force with respect to the Member. Benefits will be pro-                pation in the clinical trial; and
vided in accordance with guidelines established by the               3.   the Hospital and/or Physician conducting the clinical
Claims Administrator and developed in conjunction with                    trial is a Participating Provider, unless the protocol for
plastic and reconstructive surgeons.                                      the trial is not available through a Participating Pro-
No benefits will be provided for the following surgeries or               vider.
procedures unless determined by the Claims Administrator             Services for routine patient care will be paid on the same
to be Medically Necessary to correct or repair abnormal              basis and at the same Benefit levels as other covered Ser-
structures of the body caused by congenital defects, devel-          vices shown in the Summary of Benefits.
opmental abnormalities, trauma, infection, tumors, or dis-
ease, and which will result in more than minimal improve-            Routine patient care consists of those Services that would
ment in function or appearance:                                      otherwise be covered by the Plan if those Services were not
                                                                     provided in connection with an approved clinical trial, but
•   Surgery to excise, enlarge, reduce, or change the ap-            does not include:
    pearance of any part of the body;
                                                                     1.   Drugs or devices that have not been approved by the
•   Surgery to reform or reshape skin or bone;                            federal Food and Drug Administration (FDA);
•   Surgery to excise or reduce skin or connective tissue            2.   Services other than health care services, such as travel,
    that is loose, wrinkled, sagging, or excessive on any                 housing, companion expenses and other non-clinical
    part of the body;                                                     expenses;
•   Hair transplantation; and                                        3.   Any item or service that is provided solely to satisfy
                                                                          data collection and analysis needs and that is not used
•   Upper eyelid blepharoplasty without documented sig-
                                                                          in the clinical management of the patient;
    nificant visual impairment or symptomatology.
                                                                     4.   Services that, except for the fact that they are being
This limitation shall not apply when breast reconstruction is
                                                                          provided in a clinical trial, are specifically excluded
performed subsequent to a Medically Necessary mastec-
                                                                          under the Plan;
tomy, including surgery on either breast to achieve or re-
store symmetry.                                                      5.   Services customarily provided by the research sponsor
                                                                          free of charge for any enrollee in the trial.
CHIROPRACTIC BENEFITS                                                An approved clinical trial is limited to a trial that is:
Benefits are provided for Medically Necessary Chiropractic           1.   Approved by one of the following:
Services rendered by a chiropractor. The chiropractic
Benefit includes the initial and subsequent office visits, an             a.   one of the National Institutes of Health;
initial examination, adjustments, conjunctive therapy, and                b.   the federal Food and Drug Administration, in the
lab and X-ray Services up to the Benefit maximum.                              form of an investigational new drug application;
                                                                          c.   the United States Department of Defense;


                                                                23
     d.   the United States Veterans’ Administration; or              DURABLE MEDICAL EQUIPMENT BENEFITS
2.   Involves a drug that is exempt under federal regula-             Medically necessary Durable Medical Equipment for Ac-
     tions from a new drug application.                               tivities of Daily Living, supplies needed to operate Durable
                                                                      Medical Equipment, oxygen and its administration, and
DIABETES CARE BENEFITS                                                ostomy and medical supplies to support and maintain gas-
                                                                      trointestinal, bladder or respiratory function are covered.
Diabetes Equipment                                                    Other covered items include peak flow monitors for self-
Benefits are provided for the following devices and equip-            management of asthma, the glucose monitor for self-
ment, including replacement after the expected life of the            management of diabetes, apnea monitors for management
item and when Medically Necessary, for the management                 of newborn apnea, and the home prothrombin monitor for
and treatment of diabetes when Medically Necessary:                   specific conditions as determined by the Claims Adminis-
                                                                      trator. Benefits are provided at the most cost-effective level
1.   blood glucose monitors, including those designed to
     assist the visually impaired;                                    of care that is consistent with professionally recognized
                                                                      standards of practice. If there are two or more profession-
2.   Insulin pumps and all related necessary supplies;                ally recognized appliances equally appropriate for a condi-
3.   podiatric devices to prevent or treat diabetes-related           tion, Benefits will be based on the most cost-effective ap-
     complications, including extra-depth orthopedic shoes;           pliance.
4.   visual aids, excluding eyewear and/or video-assisting            Medically necessary Durable Medical Equipment for Ac-
     devices, designed to assist the visually impaired with           tivities of Daily Living, including repairs, is covered as
     proper dosing of Insulin.                                        described in this section, except as noted below:
For coverage of diabetic testing supplies including blood             1.   No benefits are provided for rental charges in excess of
and urine testing strips and test tablets, lancets and lancet              the purchase cost;
puncture devices and pen delivery systems for the admini-
stration of insulin, refer to the Outpatient Prescription Drug        2.   Replacement of Durable Medical Equipment is covered
Benefit section if your Employer provides Benefits for Out-                only when it no longer meets the clinical needs of the
patient prescription drugs.                                                patient or has exceeded the expected lifetime of the
                                                                           item*.
Diabetes Outpatient Self-Management Training
                                                                           *This does not apply to the Medically Necessary re-
Benefits are provided for diabetes Outpatient self-                        placement of nebulizers, face masks and tubing, and
management training, education and medical nutrition ther-                 peak flow monitors for the management and treatment
apy that is Medically Necessary to enable a Participant to                 of asthma. (Note: See the Outpatient Prescription
properly use the devices, equipment and supplies, and any                  Drug Benefit for benefits for asthma inhalers and in-
additional Outpatient self-management training, education                  haler spacers.)
and medical nutrition therapy when directed or prescribed
by the Member’s Physician. These Benefits shall include,              No benefits are provided for environmental control equip-
but not be limited to, instruction that will enable diabetic          ment, generators, self-help/educational devices, air condi-
                                                                      tioners, humidifiers, dehumidifiers, air purifiers, exercise
patients and their families to gain an understanding of the
diabetic disease process, and the daily management of dia-            equipment, or any other equipment not primarily medical in
betic therapy, in order to thereby avoid frequent hospitaliza-        nature. No benefits are provided for backup or alternate
                                                                      items.
tions and complications. Services will be covered when
provided by Physicians, registered dieticians or registered           Note: See the Diabetes Care Benefits section for devices,
nurses who are certified diabetes educators.                          equipment and supplies for the management and treatment
                                                                      of diabetes.
DIALYSIS CENTERS BENEFITS                                             For Members in a Hospice Program through a Participating
Benefits are provided for Medically Necessary dialysis Ser-           Hospice Agency, medical equipment and supplies that are
vices, including renal dialysis, hemodialysis, peritoneal             reasonable and necessary for the palliation and management of
dialysis and other related procedures.                                Terminal Illness and related conditions are provided by the
                                                                      Hospice Agency.
Included in this Benefit are Medically Necessary dialysis
related laboratory tests, equipment, medications, supplies
and dialysis self-management training for home dialysis.
                                                                      EMERGENCY ROOM BENEFITS
Note: Prior authorization by the Claims Administrator is              Benefits are provided for Medically Necessary Services
required for all dialysis Services. See the Benefits Man-             provided in the Emergency Room of a Hospital.
agement Program section for details.                                  Note: No Benefits are provided for Emergency Room Ser-
                                                                      vices resulting in an admission to a Non-Preferred Hospital
                                                                      which the Claims Administrator determines is not an emer-


                                                                 24
gency. The Participant is responsible for the entire bill for         hours per day by any of the following professional provid-
non-emergency Inpatient Hospital Services from a Non-                 ers:
Preferred Hospital.
                                                                      1.   Registered nurse;
For Emergency Room Services directly resulting in an ad-
                                                                      2.   Licensed vocational nurse;
mission to a different Hospital, the Participant is responsi-
ble for the Emergency Room Participant Copayment plus                 3.   Physical therapist, occupational therapist, or speech
the appropriate Admitting Hospital Services Participant                    therapist;
Copayment as shown on the Summary of Benefits.
                                                                      4.   Certified home health aide in conjunction with the Ser-
                                                                           vices of 1., 2. or 3. above;
FAMILY PLANNING BENEFITS
                                                                      5.   Medical social worker.
Benefits are provided for the following Family Planning
Services without illness or injury being present.                     For the purpose of this Benefit, visits from home health
                                                                      aides of 4 hours or less shall be considered as one visit.
Note: No Benefits are provided for IUDs when used for
non-contraceptive reasons except the removal to treat Medi-           In conjunction with professional Services rendered by a
cally Necessary Services related to complications.                    home health agency, medical supplies used during a cov-
                                                                      ered visit by the home health agency necessary for the
1.   Family planning counseling and consultation Services,            home health care treatment plan and related laboratory Ser-
     including Physician office visits for diaphragm fittings;        vices are covered to the extent the Benefits would have
2.   Infertility Services. Infertility Services, except as ex-        been provided had the Member remained in the Hospital or
     cluded in the Principal Limitations, Exceptions, Exclu-          Skilled Nursing Facility.
     sions and Reductions section, including professional,            This Benefit does not include medications, drugs or in-
     Hospital, ambulatory surgery center, and ancillary Ser-          jectables covered under the Home Infusion/Home Injectable
     vices to diagnose and treat the cause of Infertility. Any        Therapy Benefits or under the supplemental Benefit for
     services related to the harvesting or stimulation of the         Outpatient Prescription Drugs if your Employer provides
     human ovum (including medications, laboratory and                Benefits for Outpatient prescription drugs.
     radiology service) are not covered.
                                                                      Skilled Nursing Services are defined as a level of care that
3.   Intrauterine devices (IUDs), including insertion and/or          includes Services that can only be performed safely and
     removal;                                                         correctly by a licensed nurse (either a registered nurse or a
4.   Injectable contraceptives when administered by a Phy-            licensed vocational nurse).
     sician;                                                          Note: See the Hospice Program Services section for infor-
5.   Voluntary sterilization (tubal ligation and vasectomy)           mation about when a Member is admitted into a Hospice
     and elective abortions. No benefits are provided for             Program and a specialized description of Skilled Nursing
     contraceptives, except as may be provided under the              Services for hospice care.
     Outpatient Prescription Drug Benefit if your Employer            Note:   For information concerning diabetes self-
     provides Benefits for Outpatient prescription drugs.             management training, see the Diabetes Care Benefits sec-
                                                                      tion.
HOME HEALTH CARE BENEFITS
Benefits are provided for home health care Services when              HOME INFUSION/HOME INJECTABLE THERAPY
the Services are Medically Necessary, ordered by the at-              BENEFITS
tending Physician, and included in a written treatment plan.
                                                                      Benefits are provided for home infusion and IV injectable
Services by a Non-Participating Home Health Care Agency,              therapy, including home infusion agency skilled nursing
shift care, private duty nursing and stand-alone health aide          visits, parenteral nutrition Services, enteral nutritional Ser-
services must be prior authorized by the Claims Adminis-              vices and associated supplements, medical supplies used
trator.                                                               during a covered visit, pharmaceuticals administered intra-
                                                                      venously, related laboratory Services, and for Medically
Covered Services are subject to any applicable Deductibles
                                                                      Necessary FDA approved injectable medications when pre-
and Copayments. Visits by home health care agency pro-
                                                                      scribed by a Doctor of Medicine and provided by a home
viders will be payable up to a combined per Person per Cal-
                                                                      infusion agency.
endar Year visit maximum as shown on the Summary of
Benefits.                                                             This benefit does not include medications, drugs, Insulin,
                                                                      Insulin syringes and certain Home Self-Administered In-
Intermittent and part-time visits by a home health agency to
                                                                      jectables covered under the Outpatient Prescription Drug
provide Skilled Nursing and other skilled Services are cov-
                                                                      Benefit Supplement if your Employer provides Benefits for
ered up to 4 visits per day, 2 hours per visit not to exceed 8
                                                                      Outpatient prescription drugs.


                                                                 25
Skilled Nursing Services are defined as a level of care that         8.   Short-term Inpatient care arrangements.
includes services that can only be performed safely and
                                                                     9.   Pharmaceuticals, medical equipment, and supplies that
correctly by a licensed nurse (either a registered nurse or a
                                                                          are reasonable and necessary for the palliation and
licensed vocational nurse).
                                                                          management of Terminal Illness and related conditions.
Note: Benefits are also provided for infusion therapy pro-
                                                                     10. Physical therapy, occupational therapy, and speech-
vided in infusion suites associated with a Participating
                                                                         language pathology Services for purposes of symptom
Home Infusion Agency.
                                                                         control, or to enable the enrollee to maintain activities
                                                                         of daily living and basic functional skills.
HOSPICE PROGRAM BENEFITS
                                                                     11. Nursing care Services are covered on a continuous ba-
Benefits are provided for the following Services through a               sis for as much as 24 hours a day during Periods of Cri-
Participating Hospice Agency when an eligible Member                     sis as necessary to maintain a Member at home. Hospi-
requests admission to and is formally admitted to an ap-                 talization is covered when the Interdisciplinary Team
proved Hospice Program. The Member must have a Ter-                      makes the determination that skilled nursing care is re-
minal Illness as determined by their Physician’s certifica-              quired at a level that can’t be provided in the home.
tion and the admission must receive prior approval from the              Either Homemaker Services or Home Health Aide Ser-
Claims Administrator. (Note: Members with a Terminal                     vices or both may be covered on a 24 hour continuous
Illness who have not elected to enroll in a Hospice Program              basis during Periods of Crisis but the care provided
can receive a pre-hospice consultative visit from a Partici-             during these periods must be predominantly nursing
pating Hospice Agency.) Covered Services are available on                care.
a 24-hour basis to the extent necessary to meet the needs of
individuals for care that is reasonable and necessary for the        12. Respite Care Services are limited to an occasional basis
palliation and management of Terminal Illness and related                and to no more than five consecutive days at a time.
conditions. Members can continue to receive covered Ser-             Members are allowed to change their Participating Hospice
vices that are not related to the palliation and management          Agency only once during each Period of Care. Members
of the Terminal Illness from the appropriate provider.               can receive care for two 90-day periods followed by an
Note: Hospice services provided by a Non-Participating               unlimited number of 60-day periods. The care continues
hospice agency are not covered except in certain circum-             through another Period of Care if the Participating Provider
stances in counties in California in which there are no Par-         recertifies that the Member is Terminally ill.
ticipating Hospice Agencies and only when prior authorized
by the Claims Administrator.                                         DEFINITIONS
All of the Services listed below must be received through            Bereavement Services - services available to the immedi-
the Participating Hospice Agency.                                    ate surviving family members for a period of at least one
1.   Pre-hospice consultative visit regarding pain and symp-         year after the death of the Member. These services shall
     tom management, hospice and other care options in-              include an assessment of the needs of the bereaved family
     cluding care planning (Members do not have to be en-            and the development of a care plan that meets these needs,
     rolled in the Hospice Program to receive this Benefit).         both prior 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
3.   Skilled Nursing Services, certified health aide Services        another 4 hours in the evening. Nursing care must be pro-
     and homemaker Services under the supervision of a               vided for more than half of the period of care and must be
     qualified registered nurse.                                     provided by either a registered nurse or licensed practical
4.   Bereavement Services.                                           nurse. Homemaker Services or Home Health Aide Services
                                                                     may be provided to supplement the nursing care. When
5.   Social Services/Counseling Services with medical so-            fewer than 8 hours of nursing care are required, the services
     cial Services provided by a qualified social worker.            are covered as routine home care rather than Continuous
     Dietary counseling, by a qualified provider, shall also         Home Care.
     be provided when needed.
                                                                     Home Health Aide Services - services providing for the
6.   Medical Direction with the medical director being also          personal care of the Terminally Ill Member and the per-
     responsible for meeting the general medical needs for           formance of related tasks in the Member’s home in accor-
     the Terminal Illness of the Member to the extent that           dance with the Plan of Care in order to increase the level of
     these needs are not met by the Member’s other provid-           comfort and to maintain personal hygiene and a safe,
     ers.                                                            healthy environment for the patient.
7.   Volunteer Services.


                                                                26
Homemaker Services - services that assist in the mainte-              for hospice care even if the Member lives longer than one
nance of a safe and healthy environment and services to               year. A Period of Care starts the day the Member begins to
enable the Member to carry out the treatment plan.                    receive hospice care and ends when the 90- or 60-day pe-
                                                                      riod has ended.
Hospice Service or Hospice Program - a specialized form
of interdisciplinary health care that is designed to provide          Period of Crisis - a period in which the Member requires
palliative care, alleviate the physical, emotional, social and        continuous care to achieve palliation or management of
spiritual discomforts of a Member who is experiencing the             acute medical symptoms.
last phases of life due to the existence of a Terminal Dis-
                                                                      Plan of Care - a written plan developed by the attending
ease, to provide supportive care to the primary caregiver
                                                                      physician and surgeon, the “medical director” (as defined
and the family of the hospice patient, and which meets all
                                                                      under “Medical Direction”) or physician and surgeon des-
of the following criteria:
                                                                      ignee, and the Interdisciplinary Team that addresses the
1.   Considers the Member and the Member’s family in                  needs of a Member and family admitted to the Hospice Pro-
     addition to the Member, as the unit of care.                     gram. The Hospice shall retain overall responsibility for
                                                                      the development and maintenance of the Plan of Care and
2.   Utilizes an Interdisciplinary Team to assess the physi-
                                                                      quality of Services delivered.
     cal, medical, psychological, social and spiritual needs
     of the Member and their family.                                  Respite Care Services – short-term Inpatient care provided
                                                                      to the Member only when necessary to relieve the family
3.   Requires the interdisciplinary team to develop an over-
                                                                      members or other persons caring for the Member.
     all Plan of Care and to provide coordinated care which
     emphasizes supportive Services, including, but not lim-          Skilled Nursing Services - nursing Services provided by or
     ited to, home care, pain control, and short-term Inpa-           under the supervision of a registered nurse under a Plan of
     tient Services. Short-term Inpatient Services are in-            Care developed by the Interdisciplinary Team and the
     tended to ensure both continuity of care and appropri-           Member’s provider to the Member and his family that per-
     ateness of services for those Members who cannot be              tain to the palliative, supportive services required by the
     managed at home because of acute complications or                Member with a Terminal Illness. Skilled Nursing Services
     the temporary absence of a capable primary caregiver.            include, but are not limited to, Participant or Dependent
                                                                      assessment, evaluation, and case management of the medi-
4.   Provides for the palliative medical treatment of pain
                                                                      cal nursing needs of the Member, the performance of pre-
     and other symptoms associated with a Terminal Dis-
                                                                      scribed medical treatment for pain and symptom control,
     ease, but does not provide for efforts to cure the dis-
                                                                      the provision of emotional support to both the Member and
     ease.
                                                                      his family, and the instruction of caregivers in providing
5.   Provides for Bereavement Services following the                  personal care to the enrollee. Skilled Nursing Services pro-
     Member’s death to assist the family to cope with social          vide for the continuity of Services for the Member and his
     and emotional needs associated with the death.                   family and are available on a 24-hour on-call basis.
6.   Actively utilizes volunteers in the delivery of Hospice          Social Service/Counseling Services - those counseling and
     Services.                                                        spiritual Services that assist the Member and his family to
                                                                      minimize stresses and problems that arise from social, eco-
7.   Provides Services in the Member’s home or primary                nomic, psychological, or spiritual needs by utilizing appro-
     place of residence to the extent appropriate based on            priate community resources, and maximize positive aspects
     the medical needs of the Member.
                                                                      and opportunities for growth.
8.   Is provided through a Participating Hospice.                     Terminal Disease or Terminal Illness - a medical condi-
Interdisciplinary Team - the hospice care team that in-               tion resulting in a prognosis of life of one year or less, if the
cludes, but is not limited to, the Member and their family, a         disease follows its natural course.
physician and surgeon, a registered nurse, a social worker, a         Volunteer Services - Services provided by trained hospice
volunteer, and a spiritual caregiver.                                 volunteers who have agreed to provide service under the
Medical Direction - Services provided by a licensed physi-            direction of a hospice staff member who has been desig-
cian and surgeon who is charged with the responsibility of            nated by the Hospice to provide direction to hospice volun-
acting as a consultant to the Interdisciplinary Team, a con-          teers. Hospice volunteers may provide support and com-
sultant to the Member’s Participating Provider, as re-                panionship to the Member and his family during the re-
quested, with regard to pain and symptom management, and              maining days of the Member’s life and to the surviving
liaison with physicians and surgeons in the community. For            family following the Member’s death.
purposes of this section, the person providing these Ser-
vices shall be referred to as the “medical director”.                 HOSPITAL BENEFITS (FACILITY SERVICES)
Period of Care - the time when the Participating Provider             (Other than Mental Health Benefits, Hospice Program
recertifies that the Member still needs and remains eligible          Benefits, Skilled Nursing Facility Benefits and Dialysis



                                                                 27
Center Benefits which are described elsewhere under                  5.   Surgical supplies, dressings and cast materials, and
Covered Services)                                                         anesthetic supplies furnished by the Hospital.
                                                                     6.   Rehabilitation when furnished by the Hospital and ap-
Inpatient Services for Treatment of Illness
                                                                          proved in advance by the Claims Administrator under
or Injury
                                                                          its Benefits Management Program.
1.   Any accommodation up to the Hospital's established
                                                                     7.   Drugs and oxygen.
     semi-private room rate, or, if Medically Necessary as
     certified by a Doctor of Medicine, the intensive care           8.   Administration of blood and blood plasma, including
     unit.                                                                the cost of blood, blood plasma and blood processing.
2.   Use of operating room and specialized treatment                 9.   X-ray examination and laboratory tests.
     rooms.
                                                                     10. Radiation therapy, chemotherapy for cancer including
3.   In conjunction with a covered delivery, routine nursery             catheterization, infusion devices, and associated drugs
     care for a newborn of the Participant, covered spouse               and supplies.
     or Domestic Partner.
                                                                     11. Use of medical appliances and equipment.
4.   Reconstructive Surgery and associated covered Ser-
                                                                     12. Subacute Care.
     vices when determined by the Claims Administrator to
     be Medically Necessary and only to correct or repair            13. Inpatient Services including general anesthesia and
     abnormal structures of the body and which result in                 associated facility charges in connection with dental
     more than a minimal improvement in function or ap-                  procedures when hospitalization is required because of
     pearance. In accordance with the Women's Health &                   an underlying medical condition or clinical status and
     Cancer Rights Act, Reconstructive Surgery on either                 the Member is under the age of seven or developmen-
     breast provided to restore and achieve symmetry inci-               tally disabled regardless of age or when the Member’s
     dent to a mastectomy including treatment of physical                health is compromised and for whom general anesthe-
     complications of a mastectomy and lymphedemas is                    sia is Medically Necessary regardless of age. Excludes
     covered. For coverage of prosthetic devices incident to             dental procedures and services of a dentist or oral sur-
     a mastectomy, see Reconstructive Surgery under Pro-                 geon.
     fessional (Physician) Benefits. Any such Services
     must be received while the plan is in force with respect        14. Medically Necessary Inpatient detoxification Services
                                                                         required to treat potentially life-threatening symptoms
     to the Member. Benefits will be provided in accor-
     dance with guidelines established by the Claims Ad-                 of acute toxicity or acute withdrawal are covered when
     ministrator and developed in conjunction with plastic               a covered Member is admitted through the emergency
     and reconstructive surgeons.                                        room, or when Medically Necessary Inpatient detoxifi-
                                                                         cation is prior authorized by the Plan.
     No benefits will be provided for the following surger-
     ies or procedures unless determined by the Claims               Outpatient Services for Treatment of Illness or
     Administrator to be Medically Necessary to correct or           Injury
     repair abnormal structures of the body caused by con-           1.   Medically necessary Services provided in the Outpa-
     genital defects, developmental abnormalities, trauma,                tient Facility of a Hospital.
     infection, tumors, or disease, and which will result in
     more than minimal improvement in function or appear-            2.   Outpatient care provided by the admitting Hospital
     ance:                                                                within 24 hours before admission, when care is related
                                                                          to the condition for which Inpatient admission was
     •   Surgery to excise, enlarge, reduce, or change the                made.
         appearance of any part of the body;
                                                                     3.   Radiation therapy, chemotherapy for cancer, including
     •   Surgery to reform or reshape skin or bone;                       catheterization, infusion devices, and associated drugs
                                                                          and supplies.
     •   Surgery to excise or reduce skin or connective tis-
         sue that is loose, wrinkled, sagging, or excessive          4.   Reconstructive Surgery and associated covered Ser-
         on any part of the body;                                         vices when determined by the Claims Administrator to
                                                                          be Medically Necessary and only to correct or repair
     •   Hair transplantation; and
                                                                          abnormal structures of the body and which result in
     •   Upper eyelid blepharoplasty without documented                   more than a minimal improvement in function or ap-
         significant visual impairment or symptomatology.                 pearance. In accordance with the Women’s Health &
                                                                          Cancer Rights Act, Reconstructive Surgery on either
     This limitation shall not apply when breast reconstruc-              breast provided to restore and achieve symmetry inci-
     tion is performed subsequent to a Medically Necessary                dent to a mastectomy including treatment of physical
     mastectomy, including surgery on either breast to                    complications of a mastectomy and lymphedemas is
     achieve or restore symmetry.

                                                                28
     covered. For coverage of prosthetic devices incident to           MEDICAL TREATMENT OF TEETH, GUMS, JAW
     a mastectomy, see Reconstructive Surgery under Pro-
     fessional (Physician) Benefits. Any such Services
                                                                       JOINTS OR JAW BONES BENEFITS
     must be received while the plan is in force with respect          Benefits are provided for Hospital and professional Ser-
     to the Member. Benefits will be provided in accor-                vices provided for conditions of the teeth, gums or jaw
     dance with guidelines established by the Claims Ad-               joints and jaw bones, including adjacent tissues, only to the
     ministrator and developed in conjunction with plastic             extent that they are provided for:
     and reconstructive surgeons.
                                                                       1.   the treatment of tumors of the gums;
     No benefits will be provided for the following surger-
     ies or procedures unless determined by the Claims                 2.   the treatment of damage to natural teeth caused solely by
     Administrator to be Medically Necessary to correct or                  an accidental injury is limited to Medically Necessary
     repair abnormal structures of the body caused by con-                  Services until the Services result in initial, palliative sta-
     genital defects, developmental abnormalities, trauma,                  bilization of the Member as determined by the Plan;
     infection, tumors, or disease, and which will result in                Note: Dental services provided after initial medical
     more than minimal improvement in function or appear-                   stabilization, prosthodontics, orthodontia and cosmetic
     ance:                                                                  services are not covered. This Benefit does not include
                                                                            damage to the natural teeth that is not accidental, e.g.,
     •   Surgery to excise, enlarge, reduce, or change the
                                                                            resulting from chewing or biting.
         appearance of any part of the body;
                                                                       3.   Medically Necessary non-surgical treatment (e.g.,
     •   Surgery to reform or reshape skin or bone;
                                                                            splint and physical therapy) of Temporomandibular
     •   Surgery to excise or reduce skin or connective tis-                Joint Syndrome (TMJ);
         sue that is loose, wrinkled, sagging, or excessive            4.   surgical and arthroscopic treatment of TMJ if prior
         on any part of the body;                                           history shows conservative medical treatment has
     •   Hair transplantation; and                                          failed;

     •   Upper eyelid blepharoplasty without documented                5.   Medically Necessary treatment of maxilla and mandi-
         significant visual impairment or symptomatology.                   ble (Jaw Joints and Jaw Bones); or

     This limitation shall not apply when breast reconstruc-           6.   orthognathic surgery (surgery to reposition the upper
     tion is performed subsequent to a Medically Necessary                  and/or lower jaw) which is Medically Necessary to cor-
     mastectomy, including surgery on either breast to                      rect a skeletal deformity.
     achieve or restore symmetry.                                      No benefits are provided for:
5.   Outpatient Services including general anesthesia and              1.   services performed on the teeth, gums (other than tu-
     associated facility charges in connection with dental                  mors) and associated periodontal structures, routine
     procedures when performed in the Outpatient Facility                   care of teeth and gums, diagnostic services, preventive
     of a Hospital because of an underlying medical condi-                  or periodontic services, dental orthoses and prostheses,
     tion or clinical status and the Member is under the age                including hospitalization incident thereto;
     of seven or developmentally disabled regardless of age
     or when the Member’s health is compromised and for                2.   orthodontia (dental services to correct irregularities or
     whom general anesthesia is Medically Necessary re-                     malocclusion of the teeth) for any reason, including
     gardless of age. Excludes dental procedures and ser-                   treatment to alleviate TMJ;
     vices of a dentist or oral surgeon.                               3.   dental implants (endosteal, subperiosteal or tran-
6.   Outpatient routine newborn circumcisions.*                             sosteal);
     *For the purposes of this Benefit, routine newborn cir-           4.   any procedure (e.g., vestibuloplasty) intended to pre-
     cumcisions are circumcisions performed within 31                       pare the mouth for dentures or for the more comfortable
     days of birth unrelated to illness or injury. Routine cir-             use of dentures;
     cumcisions after this time period are covered for sick            5.   alveolar ridge surgery of the jaws if performed primar-
     babies when authorized by the Claims Administrator.                    ily to treat diseases related to the teeth, gums or perio-
Covered lab and X-ray, Physical Therapy, and Speech                         dontal structures or to support natural or prosthetic
Therapy Services provided in an Outpatient Hospital setting                 teeth;
are described under the Outpatient X-ray, Pathology and                6.   fluoride treatments except when used with radiation
Laboratory Benefits, Rehabilitation (Physical, Occupational                 therapy to the oral cavity.
and Respiratory Therapy) Benefits, and Speech Therapy
Benefits sections.                                                     See Principal Limitations, Exceptions, Exclusions and Re-
                                                                       ductions, General Exclusions for additional services that are
                                                                       not covered.

                                                                  29
MENTAL HEALTH BENEFITS                                                     lems of the foot, ankle or leg by preventing abnormal
                                                                           motion and positioning when improvement has not oc-
Benefits are provided for diagnosis and treatment by Hospi-                curred with a trial of strapping or an over-the-counter
tals, Doctors of Medicine, or Other Providers, subject to the              stabilizing device;
following conditions and limitations:
                                                                      5.   initial fitting and replacement after the expected life of
1.   Inpatient Care                                                        the orthosis is covered.
     All Inpatient Hospital care or psychiatric day care must         Benefits are provided for orthotic devices for maintaining
     be approved by the Claims Administrator, except for              normal Activities of Daily Living only. No benefits are
     emergency care, as outlined in “Hospital and Skilled             provided for orthotic devices such as knee braces intended
     Nursing Facility Admissions” of the Benefits Man-                to provide additional support for recreational or sports ac-
     agement Program section. Residential care is not cov-            tivities or for orthopedic shoes and other supportive devices
     ered.                                                            for the feet. No benefits are provided for backup or alter-
     Note: See Hospital Benefits (Facility Services), Inpa-           nate items.
     tient Services for Treatment of Illness or Injury for in-        Note: See the Diabetes Care Benefits section for devices,
     formation on Medically Necessary Inpatient detoxifica-           equipment, and supplies for the management and treatment
     tion.                                                            of diabetes.
     No benefits are provided for Substance Abuse Condi-
     tions, unless substance abuse coverage has been se-              OUTPATIENT PRESCRIPTION DRUG BENEFITS
     lected as an optional Benefit by your Employer, in               No Benefits are provided for Outpatient prescription drugs
     which case an accompanying insert provides the Bene-             under this Plan. Please contact your Employer for informa-
     fit description, limitations and Copayments. Note: In-           tion on the Outpatient prescription drug Benefits provided
     patient Services which are Medically Necessary to treat          through a separate entity other than the Claims Administra-
     the acute medical complications of detoxification are            tor.
     covered as part of the medical Benefits and are not
     considered to be treatment of the Substance Abuse
                                                                      OUTPATIENT X-RAY, PATHOLOGY AND
     Condition itself.
                                                                      LABORATORY BENEFITS
2.   Outpatient Facility and office care
                                                                      Benefits are provided for diagnostic X-ray Services, diag-
     Benefits are provided for Outpatient facility and office         nostic examinations, clinical pathology, and laboratory Ser-
     visits for Mental Health Conditions.                             vices, when provided to diagnose illness or injury. Routine
No benefits are provided for:                                         laboratory Services performed as part of a preventive health
                                                                      screening are covered under the Preventive Health Benefits
1.   telephone psychiatric consultations;                             section.
2.   testing for intelligence or learning disabilities.               Benefits are provided for genetic testing for certain condi-
The Copayments for covered Mental Health Services are                 tions when the Member has risk factors such as family his-
shown on the Summary of Benefits.                                     tory or specific symptoms. The testing must be expected to
                                                                      lead to increased or altered monitoring for early detection
                                                                      of disease, a treatment plan or other therapeutic intervention
ORTHOTICS BENEFITS                                                    and determined to be Medically Necessary and appropriate
Benefits are provided for orthotic appliances, including:             in accordance with the Claims Administrator medical pol-
                                                                      icy. (Note: See the section on Pregnancy and Maternity
1.   shoes only when permanently attached to such appli-              Care Benefits for genetic testing for prenatal diagnosis of
     ances;                                                           genetic disorders of the fetus).
2.   special footwear required for foot disfigurement which           See the section on Radiological Procedures Benefits (Re-
     includes, but is not limited to, foot disfigurement from         quiring Prior Authorization) and the Benefits Management
     cerebral palsy, arthritis, polio, spina bifida, and foot         Program section for radiological procedures which require
     disfigurement caused by accident or developmental                prior authorization by the Claims Administrator.
     disability;
3.   Medically Necessary knee braces for post-operative               PKU RELATED FORMULAS AND SPECIAL FOOD
     rehabilitation following ligament surgery, instability           PRODUCTS BENEFITS
     due to injury, and to reduce pain and instability for pa-
     tients with osteoarthritis;                                      Benefits are provided for enteral formulas, related medical
                                                                      supplies, and Special Food Products that are Medically
4.   Medically Necessary functional foot orthoses that are            Necessary for the treatment of phenylketonuria (PKU) to
     custom made rigid inserts for shoes, ordered by a Phy-           avert the development of serious physical or mental dis-
     sician or podiatrist, and used to treat mechanical prob-         abilities or to promote normal development or function as a

                                                                 30
consequence of PKU. All Benefits must be prior authorized           Benefits are provided for the following Preventive Health
by the Claims Administrator and must be prescribed and/or           Services without illness or injury being present.
ordered by the appropriate health care professional.
                                                                    1.   Annual Health Appraisal Exam
PODIATRIC SERVICES                                                       For Participants and Dependents age 3 and over, Bene-
                                                                         fits are provided for one Annual Health Appraisal
Podiatric Services include office visits and other covered               Exam in a Calendar Year.
Services customarily provided by a licensed doctor of podi-
atric medicine. Covered surgical procedures provided in                  Annual Health Appraisal Exams consist of the Office
conjunction with this Benefit are described under the Pro-               Visit and the Services listed below.
fessional (Physician) Benefits section. Covered lab and X-               a.   annual physical examination including:
ray Services provided in conjunction with this Benefit are
described under the Outpatient or Out-of-Hospital X-ray,                      1) pediatric and adult immunizations and the
Pathology and Laboratory Benefits section.                                       immunizing agent as recommended by the
                                                                                 American Academy of Pediatrics and the
PREGNANCY AND MATERNITY CARE BENEFITS                                            United States Public Health Service through
                                                                                 its U. S. Preventive Services Task Force
Benefits are provided for pregnancy and complications of                         and/or the Advisory Committee on Immuniza-
pregnancy, including prenatal diagnosis of genetic disorders                     tion Practices (ACIP) of the Centers for Dis-
of the fetus by means of diagnostic procedures in cases of                       ease Control (CDC), except for immunizations
high-risk pregnancy, and post-delivery care. (Note: See                          and vaccinations by any mode of administra-
the section on Outpatient X-ray, Pathology and Laboratory                        tion (oral, injection or otherwise) solely for
Benefits for information on coverage of other genetic test-                      the purpose of travel.
ing and diagnostic procedures.) No benefits are provided
for services after termination of coverage under this Plan                    2) vision/hearing screening to determine the need
unless the Member qualifies for an extension of Benefits as                      for eye refractions or audiograms.*
described elsewhere in this booklet.                                              *when provided to a Dependent child through
For Outpatient routine newborn circumcisions, for the pur-                        18 years of age.
poses of this Benefit, routine newborn circumcisions are                 b.   routine laboratory Services based on the Claims
circumcisions performed within 31 days of birth unrelated                     Administrator’s Preventive Health Guidelines.
to illness or injury. Routine circumcisions after this time                   These guidelines are derived from the most recent
period are covered for sick babies when authorized by the                     version with all updates of the Guide to Preventive
Claims Administrator.                                                         Services of the U.S. Preventive Services Task
Note: The Newborns’ and Mothers’ Health Protection Act                        Force as convened by the U.S. Public Health Ser-
requires group health plans to provide a minimum Hospital                     vice. Except for routine Papanicolaou tests or other
stay for the mother and newborn child of 48 hours after a                     FDA (Food and Drug Administration) approved
normal, vaginal delivery and 96 hours after a C-section                       cervical cancer screening tests which are covered
unless the attending Physician, in consultation with the                      as indicated in item c. below, routine laboratory
mother, determines a shorter Hospital length of stay is ade-                  Services include but are not limited to:
quate.                                                                        1) tuberculin test,
If the Hospital stay is less than 48 hours after a normal,                    2) screening for blood lead levels in children at
vaginal delivery or less than 96 hours after a C-section, a                      risk for lead poisoning, as determined and pre-
follow-up visit for the mother and newborn within 48 hours                       scribed by a Doctor of Medicine,
of discharge is covered when prescribed by the treating
Physician. This visit shall be provided by a licensed health                  3) venereal disease tests as recommended in the
care provider whose scope of practice includes postpartum                        Claims Administrator’s Preventive Health
and newborn care. The treating Physician, in consultation                        Guidelines,
with the mother, shall determine whether this visit shall                     4) fecal occult blood test (FOBT) for Participants
occur at home, the contracted facility, or the Physician’s                       and Dependents age 50 and older.
office.
                                                                         c.   One annual Mammography and Papanicolaou test
PREVENTIVE HEALTH BENEFITS                                                    (Pap test) or other FDA (Food and Drug Admini-
                                                                              stration) approved cervical cancer and human
Preventive Health Services are those primary preventive                       papillomavirus virus (HPV) screening tests.
medical Services provided by a Physician for the early de-
tection of disease when no symptoms are present and for
those items specifically listed below.



                                                               31
2.   Well Baby Care Benefits                                          setting such as the Physician’s office or an urgent care cen-
                                                                      ter. Services received from a Preferred Physician at an ex-
     Benefits are provided for Services of a Physician for a
                                                                      tended hours facility will be reimbursed as Physician office
     Dependent child less than 3 years of age. Well Baby
                                                                      visits. A list of urgent care providers may be found in the
     Care Benefits consist of the Services listed below.
                                                                      Preferred Provider Directory or the Online Physician Direc-
     a.   office visits including:                                    tory located at http://www.blueshieldca.com.
          1) vision/hearing screening,                                Benefits are provided for Services of Physicians for treat-
                                                                      ment of illness or injury, and for treatment of physical com-
          2) immunizations and the immunizing agent, as               plications of a mastectomy, including lymphedemas, as
             recommended by the American Academy of                   indicated below.
             Pediatrics and the United States Public Health
             Service through its U. S. Preventive Services            1.   Visits to the office, beginning with the first visit;
             Task Force and/or the Advisory Committee on
                                                                      2.   Services of consultants, including those for second
             Immunization Practices (ACIP) of the Centers
                                                                           medical opinion consultations;
             for Disease Control (CDC).
                                                                      3.   Mammography and Papanicolaou tests or other FDA
     b.   routine laboratory Services in connection with the
                                                                           (Food and Drug Administration) approved cervical cancer
          Well Baby Care Services including:
                                                                           screening tests.
          1) tuberculin tests,
                                                                      4.   Asthma self-management training and education to
          2) screening for blood lead levels in Dependent                  enable a Member to properly use asthma-related medi-
             children at risk for lead poisoning, as deter-                cation and equipment such as inhalers, spacers, nebu-
             mined and prescribed by a Doctor of Medi-                     lizers and peak flow monitors.
             cine.
                                                                      5.   Visits to the home, Hospital, Skilled Nursing Facility
3.   Colorectal Cancer Screening                                           and Emergency Room;
     For Participants and Dependents age 50 and older,                6.   Routine newborn care in the Hospital including physi-
     Benefits are provided based on the Claims Administra-                 cal examination of the baby and counseling with the
     tor’s Preventive Health Guidelines. These guidelines                  mother concerning the baby during the Hospital stay;
     regarding examinations and tests are derived from the
                                                                      7.   Surgical procedures. When multiple surgical proce-
     most recent version with all updates of the Guide to Pre-
                                                                           dures are performed during the same operation, bene-
     ventive Services of the U.S. Preventive Services Task
                                                                           fits for the secondary procedure(s) will be determined
     Force as convened by the U.S. Public Health Service and
                                                                           based on the Claims Administrator Medical Policy. No
     those of the American Cancer Society, including fre-
                                                                           benefits are provided for secondary procedures which
     quency and patient age recommendations.
                                                                           are incidental to, or an integral part of, the primary pro-
4.   Osteoporosis Screening                                                cedure;
     Benefits are provided for osteoporosis screening for             8.   Reconstructive Surgery and associated covered Ser-
     Participants and Dependents age 65 and older or 60 and                vices when determined by the Claims Administrator to
     older if at increased risk:                                           be Medically Necessary and only to correct or repair
                                                                           abnormal structures of the body and which result in
Note: See the Outpatient X-ray, Pathology and Laboratory                   more than a minimal improvement in function or ap-
Benefits section for information on coverage of genetic                    pearance. In accordance with the Women’s Health &
testing and diagnostic procedures.
                                                                           Cancer Rights Act, Reconstructive Surgery on either
                                                                           breast and surgically implanted and other prosthetic
PROFESSIONAL (PHYSICIAN) BENEFITS                                          devices (including prosthetic bras) provided to restore
(Other than Preventive Health Benefit, Mental Health                       and achieve symmetry incident to a mastectomy, and
Benefits, Hospice Program Benefits and Dialysis Center                     treatment of physical complications of a mastectomy,
Benefits which are described elsewhere under Covered                       including lymphedemas, are covered. Any such Ser-
Services.)                                                                 vices must be received while the plan is in force with
Professional Services by providers other than Physicians                   respect to the Member. Benefits will be provided in
are described elsewhere under Covered Services.                            accordance with guidelines established by the Claims
                                                                           Administrator and developed in conjunction with plas-
Covered lab and X-ray Services provided in conjunction                     tic and reconstructive surgeons.
with these Professional Services listed below, are described
under the Outpatient X-ray, Pathology and Laboratory                       No benefits will be provided for the following surger-
Benefits section.                                                          ies or procedures unless determined by the Claims
                                                                           Administrator to be Medically Necessary to correct or
Note: A Preferred Physician may offer extended hour and                    repair abnormal structures of the body caused by con-
urgent care Services on a walk-in basis in a non-hospital                  genital defects, developmental abnormalities, trauma,

                                                                 32
     infection, tumors, or disease, and which will result in           5.   Repairs, even if due to damage.
     more than minimal improvement in function or appear-
                                                                       No benefits are provided for wigs for any reason or any
     ance:
                                                                       type of speech or language assistance devices (except as
     •   Surgery to excise, enlarge, reduce, or change the             specifically provided). No benefits are provided for backup
         appearance of any part of the body;                           or alternate items.
     •   Surgery to reform or reshape skin or bone;                    Benefits are provided for contact lenses, if Medically Nec-
                                                                       essary to treat eye conditions such as keratoconus, keratitis
     •   Surgery to excise or reduce skin or connective tis-           sicca or aphakia following cataract surgery when no in-
         sue that is loose, wrinkled, sagging, or excessive            traocular lens has been implanted. Note: These contact
         on any part of the body;                                      lenses will not be covered under your Plan if your Em-
     •   Hair transplantation; and                                     ployer provides supplemental Benefits for vision care that
                                                                       cover contact lenses through a vision plan purchased
     •   Upper eyelid blepharoplasty without documented                through the Claims Administrator. There is no coordination
         significant visual impairment or symptomatology.              of benefits between the health Plan and the vision plan for
     This limitation shall not apply when breast reconstruc-           these Benefits.
     tion is performed subsequent to a Medically Necessary             For surgically implanted and other prosthetic devices (in-
     mastectomy, including surgery on either breast to                 cluding prosthetic bras) provided to restore and achieve
     achieve or restore symmetry;                                      symmetry incident to a mastectomy, see Reconstructive
9.   Chemotherapy for cancer, including catheterization,               Surgery under Professional (Physician) Benefits. Surgi-
     and associated drugs and supplies;                                cally implanted prostheses including, but not limited to,
                                                                       Blom-Singer and artificial larynx prostheses for speech
10. Extra time spent when a Physician is detained to treat a           following a laryngectomy are covered as a surgical profes-
    Member in critical condition;                                      sional benefit.
11. Necessary preoperative treatment;
                                                                       RADIOLOGICAL PROCEDURES BENEFITS
12. Treatment of burns;                                                (REQUIRING PRIOR AUTHORIZATION)
13. Outpatient routine newborn circumcisions.*
                                                                       The following radiological procedures, when performed on
     *For the purposes of this Benefit, routine newborn cir-           an Outpatient, non-emergency basis, require prior authori-
     cumcisions are circumcisions performed within 31                  zation by the Claims Administrator under the Benefits Man-
     days of birth unrelated to illness or injury. Routine cir-        agement Program. Failure to obtain this authorization will
     cumcisions after this time period are covered for sick            result in non-payment for procedures which are determined
     babies when authorized by the Claims Administrator.               not to be covered Services.
                                                                       See the Benefits Management Program section for complete
PROSTHETIC APPLIANCES BENEFITS                                         information.
Medically Necessary Prostheses for Activities of Daily Liv-            1.   CT (Computerized Tomography) scans;
ing are covered. Benefits are provided at the most cost-
effective level of care that is consistent with professionally         2.   MRIs (Magnetic Resonance Imaging);
recognized standards of practice. If there are two or more             3.   MRAs (Magnetic Resonance Angiography);
professionally recognized appliances equally appropriate
for a condition, Benefits will be based on the most cost-              4.   PET (Positron Emission Tomography) scans; and
effective appliance. See General Exclusions under the Prin-            5.   any cardiac diagnostic procedure utilizing Nuclear
cipal Limitations, Exceptions, Exclusions and Reductions                    Medicine.
section for a listing of excluded speech and language assis-
tance devices.
                                                                       REHABILITATION BENEFITS (PHYSICAL,
Benefits are provided for Medically Necessary Prostheses               OCCUPATIONAL AND RESPIRATORY THERAPY)
for Activities of Daily Living, including the following:
                                                                       Benefits are provided for Outpatient Physical, Occupa-
1.   Surgically implanted prostheses including, but not lim-           tional, and/or Respiratory Therapy pursuant to a written
     ited to, Blom-Singer and artificial larynx prostheses for         treatment plan for as long as continued treatment is Medi-
     speech following a laryngectomy;                                  cally Necessary and when rendered in the provider’s office
2.   Artificial limbs and eyes;                                        or Outpatient department of a Hospital. Benefits for Speech
                                                                       Therapy are described in the section on Speech Therapy
3.   Supplies necessary for the operation of Prostheses;               Benefits. The Claims Administrator reserves the right to
4.   Initial fitting and replacement after the expected life of        periodically review the provider’s treatment plan and re-
     the item;                                                         cords. If the Claims Administrator determines that contin-


                                                                  33
ued treatment is not Medically Necessary and not provided              likely to result in clinically significant progress as measured
with the expectation that the patient has restorative potential        by objective and standardized tests. The provider’s treat-
pursuant to the treatment plan, the Claims Administrator               ment plan and records will be reviewed periodically. When
will notify the Participant of this determination and benefits         continued treatment is not Medically Necessary pursuant to
will not be provided for services rendered after the date of           the treatment plan, not likely to result in additional clini-
the written notification.                                              cally significant improvement, or no longer requires skilled
                                                                       services of a licensed speech therapist, the Member will be
Note: Outpatient Rehabilitation Benefits are limited to a
                                                                       notified of this determination and benefits will not be pro-
combined per Member per Calendar Year visit maximum
                                                                       vided for services rendered after the date of written notifi-
with chiropractic Services as shown in the Summary of
                                                                       cation.
Benefits.
                                                                       Except as specified above and as stated under the Home
Note: See the Home Health Care Benefits and Hospice
                                                                       Health Care Benefits and the Hospice Program Benefits
Program Benefits sections for information on coverage for
                                                                       sections, no Outpatient benefits are provided for Speech
Rehabilitation Services rendered in the home.
                                                                       Therapy, speech correction, or speech pathology services.
Note: Covered lab and X-ray Services provided in conjunc-
                                                                       Note: See the Home Health Care Benefits section for in-
tion with this Benefit are paid as shown under the Outpa-
                                                                       formation on coverage for Speech Therapy Services ren-
tient X-Ray, Pathology and Laboratory Benefits section.
                                                                       dered in the home. See the Inpatient Services for Treatment
Services provided by a chiropractor are not included in this           of Illness or Injury section for information on Inpatient
Rehabilitation benefit. See the section on Chiropractic                Benefits and the Hospice Program Benefits section.
Benefits.
                                                                       TRANSPLANT BENEFITS
SKILLED NURSING FACILITY BENEFITS
(Other than Hospice Program Benefits which are de-                     Organ Transplants
scribed elsewhere under Covered Services.)                             Benefits are provided for Hospital and professional Services
Benefits are provided for Medically Necessary Services                 provided in connection with human organ transplants only to
provided by a Skilled Nursing Facility Unit of a Hospital or           the extent that:
by a 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          2.   the recipient of such transplant is a Participant or De-
the Benefit maximum as shown on the Summary of Bene-                        pendent.
fits. The Benefit maximum is per Member per Calendar
Year, except that room and board charges in excess of the              Benefits are provided for Services incident to obtaining the
facility’s established semi-private room rate are excluded.            human organ transplant material from a living donor or an
                                                                       organ transplant “bank” and will be charged against the
                                                                       maximum aggregate payment amount.
SPEECH THERAPY BENEFITS
Initial Outpatient Benefits for Speech Therapy Services are            Special Transplant
covered when diagnosed and ordered by a Physician and                  Benefits are provided for certain procedures, listed below,
provided by an appropriately licensed speech therapist, pur-           only if (1) performed at a Special Transplant Facility con-
suant to a written treatment plan for an appropriate time to:          tracting with the Claims Administrator to provide the pro-
(1) correct or improve the speech abnormality, or (2) to               cedure, or in the case of Members accessing this Benefit
evaluate the effectiveness of treatment, and when rendered             outside of California, the procedure is performed at a trans-
in the provider’s office or Outpatient department of a Hos-            plant facility designated by the Claims Administrator, (2)
pital. Before initial services are provided, you or your pro-          prior authorization is obtained, in writing, from the Claims
vider should determine if the proposed treatment will be cov-          Administrator's Medical Director and (3) the recipient of
ered by following the Claims Administrator’s prior authori-            the transplant is a Participant or Dependent.
zation procedures. (See the section on the Benefits Manage-
ment Program.)                                                         The Claims Administrator reserves the right to review all
                                                                       requests for prior authorization for these Special Transplant
Services are provided for the correction of, or clinically             Benefits, and to make a decision regarding benefits based
significant improvement of, speech abnormalities that are              on (1) the medical circumstances of each Member, and (2)
the likely result of a diagnosed and identifiable medical              consistency between the treatment proposed and the Claims
condition, illness, or injury to the nervous system or to the          Administrator medical policy. Failure to obtain prior written
vocal, swallowing, or auditory organs.                                 authorization as described above and/or failure to have the
Continued Outpatient Benefits will be provided for Medi-               procedure performed at a contracting Special Transplant Fa-
cally Necessary Services as long as continued treatment is             cility will result in denial of claims for this Benefit.
Medically Necessary, pursuant to the treatment plan, and

                                                                  34
The following procedures are eligible for coverage under                Program Benefits (see Hospice Program
this provision:                                                         Benefits for exception);
1.   Human heart transplants;
                                                                     4. performed in a Hospital by house officers,
2.   Human lung transplants;                                            residents, interns and others in training;
3.   Human heart and lung transplants in combination;
                                                                     5. performed by a Close Relative or by a person
4.   Human liver transplants;                                           who ordinarily resides in the covered Mem-
5.   Human kidney and pancreas transplants in combina-                  ber's home;
     tion;
                                                                     6. for any services relating to the diagnosis or
6.   Human bone marrow transplants, including autologous                treatment of any mental or emotional illness
     bone marrow transplantation (ABMT) or autologous pe-               or disorder that is not a Mental Health Condi-
     ripheral stem cell transplantation used to support high-
     dose chemotherapy when such treatment is Medically                 tion;
     Necessary and is not Experimental or Investigational;           7. for any services whatsoever relating to the
7.   Pediatric human small bowel transplants;                           diagnosis or treatment of any Substance
8.   Pediatric and adult human small bowel and liver trans-             Abuse Condition, unless your Employer has
     plants in combination.                                             purchased substance abuse coverage as an op-
Benefits are provided for Services incident to obtaining the
                                                                        tional Benefit, in which case an accompany-
transplant material from a living donor or an organ trans-              ing insert provides the Benefit description,
plant bank. Benefits will be charged against the maximum                limitations and Copayments;
aggregate payment amount.
                                                                     8. for hearing aids, except as specifically pro-
PRINCIPAL LIMITATIONS, EXCEPTIONS,                                      vided under Prosthetic Appliances Benefits;
EXCLUSIONS AND REDUCTIONS                                            9. for Services rendered by Non-Preferred Pro-
                                                                        viders except as may be provided under
GENERAL EXCLUSIONS                                                      Emergency Room Benefits;
Unless exceptions to the following exclusions are                    10. for eye refractions, surgery to correct refrac-
specifically made elsewhere in this booklet, no                          tive error (such as but not limited to radial
benefits are provided for services or supplies                           keratotomy, refractive keratoplasty), lenses
which are:                                                               and frames for eyeglasses, and contact lenses
                                                                         except as specifically listed under Prosthetic
1. for or incident to hospitalization or confine-
                                                                         Appliances Benefits, and video-assisted visual
   ment in a pain management center to treat or
                                                                         aids or video magnification equipment for any
   cure chronic pain, except as may be provided
                                                                         purpose;
   through a Participating Hospice Agency and
   except as Medically Necessary;                                    11. for any type of communicator, voice enhan-
                                                                         cer, voice prosthesis, electronic voice produc-
2. for Rehabilitation Services, except as specifi-
                                                                         ing machine, or any other language assistive
   cally provided in the Inpatient Services for
                                                                         devices, except as specifically listed under
   Treatment of Illness or Injury, Home Health
                                                                         Prosthetic Appliances Benefits;
   Care Benefits, Rehabilitation Benefits (Physi-
   cal, Occupational, and Respiratory Therapy)                       12. for routine physical examinations, except as
   and Hospice Program Benefits sections;                                specifically listed under Preventive Health
                                                                         Benefits, or for immunizations and vaccina-
3. for or incident to services rendered in the
                                                                         tions by any mode of administration (oral, in-
   home or hospitalization or confinement in a
                                                                         jection or otherwise) solely for the purpose of
   health facility primarily for rest, Custodial,
                                                                         travel, or for examinations required for licen-
   Maintenance, Domiciliary Care, or Residen-
                                                                         sure, employment, or insurance unless the ex-
   tial Care except as provided under Hospice
                                                                         amination is substituted for the Annual Health
                                                                         Appraisal Exam;

                                                                35
13. for or incident to acupuncture, except as may                counter shoe inserts or arch supports), except
    be provided under Acupuncture Benefits;                      as specifically listed under Orthotics Benefits
                                                                 and Diabetes Care Benefits; bunions; or mus-
14. for or incident to Speech Therapy, speech cor-
                                                                 cle trauma due to exertion; or any type of
    rection or speech pathology or speech abnor-
                                                                 massage procedure on the foot;
    malities that are not likely the result of a di-
    agnosed, identifiable medical condition, in-              21. which are Experimental or Investigational in
    jury or illness except as specifically listed un-             nature, except for Services for Members who
    der Home Health Care Benefits, Speech Ther-                   have been accepted into an approved clinical
    apy Benefits and Hospice Program Benefits;                    trial for cancer as provided under Clinical
                                                                  Trial for Cancer Benefits;
15. for drugs and medicines which cannot be law-
    fully marketed without approval of the U.S.               22. for learning disabilities or behavioral prob-
    Food and Drug Administration (the FDA);                       lems or social skills training/therapy;
    however, drugs and medicines which have re-               23. hospitalization primarily for X-ray, laboratory
    ceived FDA approval for marketing for one or                  or any other diagnostic studies or medical ob-
    more uses will not be denied on the basis that                servation;
    they are being prescribed for an off-label use;
                                                              24. for dental care or services incident to the
16. for or incident to vocational, educational, rec-              treatment, prevention or relief of pain or dys-
    reational, art, dance, music or reading ther-                 function of the Temporomandibular Joint
    apy; weight control programs; exercise pro-                   and/or muscles of mastication, except as spe-
    grams; or nutritional counseling except as                    cifically provided under Medical Treatment of
    specifically provided for under Diabetes Care                 Teeth, Gums, Jaw Joints or Jaw Bones Bene-
    Benefits;                                                     fits and Hospital Benefits (Facility Services) ;
17. for transgender or gender dysphoria condi-                25. 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 re-                  tumors) and associated periodontal structures,
    lated services, or any resulting medical com-                 including but not limited to diagnostic, pre-
    plications, except for treatment of medical                   ventive, orthodontic and other services such
    complications that is Medically Necessary;                    as dental cleaning, tooth whitening, X-rays,
18. for sexual dysfunctions and sexual inadequa-                  topical fluoride treatment except when used
    cies, except as provided for treatment of or-                 with radiation therapy to the oral cavity, fill-
    ganically based conditions;                                   ings, and root canal treatment; treatment of
                                                                  periodontal disease or periodontal surgery for
19. for or incident to the treatment of Infertility,
                                                                  inflammatory conditions; tooth extraction;
    including the cause of Infertility, or any form
                                                                  dental implants, braces, crowns, dental or-
    of assisted reproductive technology, including
                                                                  thoses and prostheses; except as specifically
    but not limited to reversal of surgical steriliza-
                                                                  provided under Medical Treatment of Teeth,
    tion, or any resulting complications, except
                                                                  Gums, Jaw Joints or Jaw Bones Benefits and
    for Medically Necessary treatment of medical
                                                                  Hospital Benefits (Facility Services);
    complications;
                                                              26. incident to organ transplant, except as explic-
20. for callus, corn paring or excision and toenail
                                                                  itly listed under Transplant Benefits;
    trimming except as may be provided through
    a Participating Hospice Agency; treatment                 27. for Cosmetic Surgery or any resulting com-
    (other than surgery) of chronic conditions of                 plications, except that Benefits are provided
    the foot, e.g., weak or fallen arches; flat or                for Medically Necessary Services to treat
    pronated foot; pain or cramp of the foot; for                 complications of cosmetic surgery (e.g., in-
    special footwear required for foot disfigure-                 fections or hemorrhages), when reviewed and
    ment (e.g., non-custom made or over-the-                      approved by the Claims Administrator con-

                                                         36
   sultant. Without limiting the foregoing, no               33. in connection with private duty nursing, ex-
   benefits will be provided for the following                   cept as provided under Home Health Care
   surgeries or procedures:                                      Benefits, Home Infusion/Home Injectable
                                                                 Therapy Benefits, and except as provided
   •   Lower eyelid blepharoplasty;
                                                                 through a Participating Hospice Agency;
   •   Spider veins;
                                                             34. for prescription and non-prescription food and
   •   Services and procedures to smooth the                     nutritional supplements, except as provided
       skin (e.g., chemical face peels, laser resur-             under Home Infusion/Home Injectable Ther-
       facing, and abrasive procedures);                         apy Benefits, and PKU Related Formulas and
                                                                 Special Food Products Benefit and except as
   •   Hair removal by electrolysis or other
                                                                 provided through a Participating Hospice
       means; and
                                                                 Agency;
   •   Reimplantation of breast implants origi-              35. for home testing devices and monitoring
       nally provided for cosmetic augmentation;                 equipment except as specifically provided un-
28. for Reconstructive Surgery and procedures in                 der Durable Medical Equipment Benefits;
    situations: 1) where there is another more ap-           36. for contraceptives, except as specifically in-
    propriate surgical procedure that is approved                cluded in Family Planning Benefits; oral con-
    by the Claims Administrator Physician con-                   traceptives and diaphragms are excluded; no
    sultant, or 2) when the surgery or procedure                 benefits are provided for contraceptive im-
    offers only a minimal improvement in func-                   plants;
    tion or in the appearance of the enrollees, e.g.,
    spider veins, or 3) as limited under Ambula-             37. for genetic testing except as described under
    tory Surgery Center Benefits, Hospital Bene-                 Outpatient X-ray, Pathology and Laboratory
    fits (Facility Services), and Professional (Phy-             Benefits and Pregnancy and Maternity Care
    sician) Benefits;                                            Benefits;
29. for penile implant devices and surgery, and              38. for non-prescription (over-the-counter) medi-
    any related services, except for any resulting               cal equipment or supplies that can be pur-
    complications and Medically Necessary Ser-                   chased without a licensed provider's prescrip-
    vices;                                                       tion order, even if a licensed provider writes a
                                                                 prescription order for a non-prescription item,
30. for patient convenience items such as tele-                  except as specifically provided under Home
    phone, television, guest trays, and personal                 Health Care Benefits, Home Infusion/Home
    hygiene items;                                               Injectable Therapy Benefits, Hospice Program
31. for which the Member is not legally obligated                Benefits, Diabetes Care Benefits, Durable
    to pay, or for services for which no charge is               Medical Equipment Benefits, and Prosthetic
    made;                                                        Appliances Benefits;
32. incident to any injury or disease arising out            39. for any services related to assisted reproduc-
    of, or in the course of, any employment for                  tive technology, including but not limited to
    salary, wage or profit if such injury or disease             the harvesting or stimulation of the human
    is covered by any workers’ compensation law,                 ovum, in vitro fertilization, Gamete Intrafal-
    occupational disease law or similar legisla-                 lopian Transfer (GIFT) procedure, artificial
    tion. However, if the Claims Administrator                   insemination (including related medications,
    provides payment for such services, it will be               laboratory, and radiology services), services
    entitled to establish a lien upon such other                 or medications to treat low sperm count, or
    benefits up to the amount paid by the Claims                 services incident to or resulting from proce-
    Administrator for the treatment of such injury               dures for a surrogate mother who is otherwise
    or disease;

                                                        37
    not eligible for covered Pregnancy Benefits                       ceive benefits for end-stage renal disease
    under the Claims Administrator health plan;                       from Medicare.
40. for services provided by an individual or en-              2. Your Claims Administrator group plan will
    tity that is not licensed or certified by the state           provide benefits after Medicare in the follow-
    to provide health care services, or is not oper-              ing situations:
    ating within the scope of such license or certi-
                                                                  a. When you are eligible for Medicare due to
    fication, except as specifically stated herein;
                                                                     age, if the Participant is actively working
41. for Outpatient prescription drugs;                               for a group that employs less than 20 em-
                                                                     ployees (as defined by Medicare Secon-
42. not specifically listed as a Benefit.
                                                                     dary Payer laws).
MEDICAL NECESSITY EXCLUSION                                       b. When you are eligible for Medicare due to
The Benefits of this Plan are intended only for                      disability, if the Participant is covered by
Services that are Medically Necessary. Because a                     a group that employs less than 100 em-
Physician or other provider may prescribe, order,                    ployees (as defined by Medicare Secon-
recommend, or approve a service or supply does                       dary Payer laws).
not, in itself, make it medically necessary even                  c. When you are eligible for Medicare solely
though it is not specifically listed as an exclusion                 due to end-stage renal disease after the
or limitation. The Claims Administrator reserves                     first 30 months that you are eligible to re-
the right to review all claims to determine if a ser-                ceive benefits for end-stage renal disease
vice or supply is medically necessary. The                           from Medicare.
Claims Administrator may use the services of
Doctor of Medicine consultants, peer review                       d. When you are retired and age 65 years or
committees of professional societies or Hospitals                    older.
and other consultants to evaluate claims. The                     When your Claims Administrator group plan
Claims Administrator may limit or exclude bene-                   provides benefits after Medicare, the com-
fits for services which are not necessary.                        bined benefits from Medicare and your
                                                                  Claims Administrator group plan will equal,
LIMITATIONS FOR DUPLICATE COVERAGE                                but not exceed, what the Claims Administra-
When you are eligible for Medicare                                tor would have paid if you were not eligible to
                                                                  receive benefits from Medicare (based on the
1. Your Claims Administrator group plan will                      lower of the Claims Administrator’s Allow-
   provide benefits before Medicare in the fol-                   able Amount or the Medicare allowed
   lowing situations:                                             amount). Your Claims Administrator group
    a. When you are eligible for Medicare due to                  plan Deductible and copayments will be
       age, if the Participant is actively working                waived.
       for a group that employs 20 or more em-                 When you are eligible for Medi-Cal
       ployees (as defined by Medicare Secon-
       dary Payer laws).                                       Medi-Cal always provides benefits last.
    b. When you are eligible for Medicare due to               When you are a qualified veteran
       disability, if the Participant is covered by            If you are a qualified veteran your Claims Ad-
       a group that employs 100 or more em-                    ministrator group plan will pay the reasonable
       ployees (as defined by Medicare Secon-                  value or the Claims Administrator’s Allowable
       dary Payer laws).                                       Amount for covered Services provided to you at a
    c. When you are eligible for Medicare solely               Veteran’s Administration facility for a condition
       due to end-stage renal disease during the               that is not related to military service. If you are a
       first 30 months that you are eligible to re-            qualified veteran who is not on active duty, your
                                                               Claims Administrator group plan will pay the rea-

                                                          38
sonable value or the Claims Administrator’s Al-             the reasonable costs of the Services provided to
lowable Amount for covered Services provided to             the Member paid on a fee-for-service basis.
you at a Department of Defense facility, even if            The Member is required to:
provided for conditions related to military ser-
vice.                                                       1. Notify the Plan Administrator in writing of
                                                               any actual or potential claim or legal action
When you are covered by another government                     which such Member anticipates bringing or
agency                                                         has brought against the third party arising
If you are also entitled to benefits under any other           from the alleged acts or omissions causing the
federal or state governmental agency, or by any                injury or illness, not later than 30 days after
municipality, county or other political subdivi-               submitting or filing a claim or legal action
sion, the combined benefits from that coverage                 against the third party; and
and your Claims Administrator group plan will               2. Agree to fully cooperate with the Plan Ad-
equal, but not exceed, what the Claims Adminis-                ministrator to execute any forms or docu-
trator would have paid if you were not eligible to             ments needed to assist them in exercising
receive benefits under that coverage (based on the             their equitable right to restitution or other
reasonable value or the Claims Administrator’s                 available remedies; and
Allowable Amount).
                                                            3. Provide the Plan Administrator with a lien, in
Contact the Customer Service department at the                 the amount of reasonable costs of benefits
telephone number shown at the end of this docu-                provided, calculated in accordance with Cali-
ment if you have any questions about how the                   fornia Civil Code section 3040. The lien may
Claims Administrator coordinates your group                    be filed with the third party, the third party's
plan benefits in the above situations.                         agent or attorney, or the court, unless other-
EXCEPTION FOR OTHER COVERAGE                                   wise prohibited by law.

Participating Providers and Preferred Providers             A Member’s failure to comply with 1. through 3.
may seek reimbursement from other third party               above shall not in any way act as a waiver, re-
payers for the balance of their reasonable charges          lease, or relinquishment of the rights of the Plan
for Services rendered under this Plan.                      Administrator.
                                                            Further, if the Member receives Services from a
CLAIMS REVIEW                                               Participating Hospital for such injuries, the Hos-
The Claims Administrator reserves the right to              pital has the right to collect from the Member the
review all claims to determine if any exclusions            difference between the amount paid by the
or other limitations apply. The Claims Adminis-             Claims Administrator and the Hospital’s reason-
trator may use the services of Physician consult-           able and necessary charges for such Services
ants, peer review committees of professional so-            when payment or reimbursement is received by
cieties or Hospitals and other consultants to               the Member for medical expenses. The Plan
evaluate claims.                                            Hospital’s right to collect shall be in accordance
                                                            with California Civil Code Section 3045.1.
REDUCTIONS
                                                            TERMINATION OF BENEFITS
Third-Party Liability - If a Member is injured
                                                            Except as specifically provided under the Extension of
through the act or omission of another person (a
                                                            Benefits provision, and, if applicable, the Continuation of
“third party”), the Claims Administrator shall,             Group Coverage provision, there is no right to receive bene-
with respect to Services required as a result of            fits for services provided following termination of this
that injury, provide the Benefits of the Plan and           health Plan.
the Plan Administrator have an equitable right to           Coverage for you or your Dependents terminates at 12:01
restitution or other available remedy to recover            a.m. Pacific Time on the earliest of these dates: (1) the date
                                                            the Plan is discontinued, (2) the first day of the month fol-


                                                       39
lowing the month in which the Participant’s employment                 will extend the Benefits of this Plan, subject to all limita-
terminates, unless a different date has been agreed to between         tions and restrictions, for covered Services and supplies
the Claims Administrator and your Employer, (3) fifteen                directly related to the condition, illness, or injury causing
(15) days following the date of mailing of the notice to the           such Total Disability until the first to occur of the follow-
Employer that fees are not paid; or (4) on the first day of the        ing: (1) 12:01 a.m. on the day following a period of twelve
month following the month in which you or your Dependents              months from the date coverage terminated; (2) the date the
become ineligible. A spouse also becomes ineligible follow-            covered Member is no longer Totally Disabled; (3) the date
ing legal separation from the Participant, entry of a final de-        on which the covered Member’s maximum Benefits are
cree of divorce, annulment or dissolution of marriage from             reached; (4) the date on which a replacement carrier pro-
the Participant. A Domestic Partner becomes ineligible upon            vides coverage to the Member that is not subject to a pre-
termination of the domestic partnership.                               existing condition exclusion. The time the Member was
                                                                       covered under this Plan will apply toward the replacement
If you cease work because of retirement, disability, leave of
                                                                       plan’s pre-existing condition exclusion.
absence, temporary layoff, or termination, see your Em-
ployer about possibly continuing group coverage. Also see              No extension will be granted unless the Claims Administra-
the Individual Conversion Plan provision, and, if applica-             tor receives written certification of such Total Disability
ble, the Continuation of Group Coverage provision in this              from a licensed Doctor of Medicine (M.D.) within 90 days
booklet for information on continuation of coverage.                   of the date on which coverage was terminated, and thereaf-
                                                                       ter at such reasonable intervals as determined by the Claims
If your Employer is subject to the federal Family & Medical
                                                                       Administrator.
Leave Act of 1993, and the approved leave of absence is for
family leave under the terms of such Act(s), your payment
of fees will keep your coverage in force for such period of            COORDINATION OF BENEFITS
time as specified in such Act(s). Your Employer is solely              When a Member who is covered under this group Plan is
responsible for notifying you of the availability and dura-            also covered under another group plan, or selected group, or
tion of family leaves.                                                 blanket disability insurance contract, or any other contrac-
The Claims Administrator may terminate your and your                   tual arrangement or any portion of any such arrangement
Dependent’s coverage for cause immediately upon written                whereby the members of a group are entitled to payment of
notice to you and your Employer for the following:                     or reimbursement for Hospital or medical expenses, such
                                                                       Member will not be permitted to make a “profit” on a dis-
1.   Material information that is false, or misrepresented             ability by collecting benefits in excess of actual cost during
     information provided on the enrollment application or             any Calendar Year. Instead, payments will be coordinated
     given to your Employer or the Claims Administrator;               between the plans in order to provide for “allowable ex-
2.   Permitting use of your Participant identification card            penses” (these are the expenses that are Incurred for ser-
     by someone other than yourself or your Dependents to              vices and supplies covered under at least one of the plans
     obtain Services;                                                  involved) up to the maximum benefit amount payable by
                                                                       each plan separately.
3.   Obtaining or attempting to obtain Services under the
     group by means of false, materially misleading, or                If the covered Member is also entitled to benefits under any
     fraudulent information, acts or omissions;                        of the conditions as outlined under the “Limitations for Du-
                                                                       plicate Coverage” provision, benefits received under any
4.   Abusive or disruptive behavior which: (1) threatens the           such condition will not be coordinated with the benefits of
     life or well-being of the Claims Administrator person-            this Plan.
     nel and providers of Services, or, (2) substantially im-
     pairs the ability of the Claims Administrator to arrange          The following rules determine the order of benefit pay-
     for services to the Member, or, (3) substantially im-             ments:
     pairs the ability of providers of Service to furnish Ser-         When the other plan does not have a coordination of benefits
     vices to the Member or to other patients.                         provision it will always provide its benefits first. Otherwise,
If a written application for the addition of a newborn or a            the plan covering the Member as an Employee will provide its
child placed for adoption is not submitted to and received             benefits before the plan covering the Member as a Dependent.
by the Claims Administrator within the 31 days following               The plan which covers the Member as a Dependent of a
that Dependent’s effective date of coverage, Benefits under            Member whose date of birth, (excluding year of birth), oc-
this Plan will be terminated on the 32nd day at 12:01 a.m.             curs earlier in a Calendar Year, will determine its benefits
Pacific Time.                                                          before a plan which covers that Member as a Dependent of
                                                                       a Member whose date of birth, (excluding year of birth),
EXTENSION OF BENEFITS                                                  occurs later in a Calendar Year. If either plan does not have
                                                                       the provisions of this paragraph regarding Dependents,
If a Member becomes Totally Disabled while validly cov-
                                                                       which results either in each plan determining its benefits
ered under this Plan and continues to be Totally Disabled              before the other or in each plan determining its benefits
on the date the Plan terminates, the Claims Administrator

                                                                  40
after the other, the provisions of this paragraph will not            If payments which should have been made under this Plan
apply, and the rule set forth in the plan which does not have         in accordance with these provisions have been made by
the provisions of this paragraph will determine the order of          another plan, the Claims Administrator may pay to the other
benefits.                                                             plan the amount necessary to satisfy the intent of these pro-
                                                                      visions. This amount shall be considered as Benefits paid
1.   In the case of a claim involving expenses for a De-
                                                                      under this Plan. The Claims Administrator shall be fully
     pendent child whose parents are separated or divorced,
                                                                      discharged from liability under this Plan to the extent of
     plans covering the child as a Dependent will determine
                                                                      these payments.
     their respective benefits in the following order:
                                                                      If payments have been made by the Claims Administrator
     First, the plan of the parent with custody of the child;
                                                                      in excess of the maximum amount of payment necessary to
     then, if that parent has remarried, the plan of the step-
                                                                      satisfy these provisions, the Claims Administrator shall
     parent with custody of the child; and finally the plan(s)
                                                                      have the right to recover the excess from any person or
     of the parent(s) without custody of the child.
                                                                      other entity to or with respect to whom such payments were
2.   Regardless of (1.) above, if there is a court decree             made.
     which otherwise establishes financial responsibility for
                                                                      The Claims Administrator may release to or obtain from
     the medical, dental or other health care expenses of the
                                                                      any organization or person any information which the
     child, then the plan which covers the child as a De-
                                                                      Claims Administrator considers necessary for the purpose
     pendent of that parent will determine its benefits before
                                                                      of determining the applicability of and implementing the
     any other plan which covers the child as a Dependent
                                                                      terms of these provisions or any provisions of similar pur-
     child.
                                                                      pose of any other plan. Any person claiming Benefits un-
3.   If the above rules do not apply, the plan which has cov-         der this Plan shall furnish the Claims Administrator with
     ered the Member for the longer period of time will de-           such information as may be necessary to implement these
     termine its benefits first, provided that:                       provisions.
     a.   a plan covering a Member as a laid-off or retired
          Employee, or as a Dependent of that Member will             GROUP CONTINUATION COVERAGE AND
          determine its benefits after any other plan covering        INDIVIDUAL CONVERSION PLAN
          that Member as an Employee, other than a laid-off
          or retired Employee, or such Dependent; and
                                                                      CONTINUATION OF GROUP COVERAGE
     b.   if either plan does not have a provision regarding
                                                                      Please examine your options carefully before declining this
          laid-off or retired Employees, which results in
                                                                      coverage. You should be aware that companies selling in-
          each plan determining its benefits after the other,
                                                                      dividual health insurance typically require a review of your
          then paragraph (a.) above will not apply.
                                                                      medical history that could result in a higher premium or you
If this Plan is the primary carrier in the case of a covered          could be denied coverage entirely.
Member, then this Plan will provide its Benefits without
                                                                      Applicable to Members when the Participant’s Employer is
making any reduction because of benefits available from
                                                                      subject to either Title X of the Consolidated Omnibus
any other plan, except that Physician Members and other
                                                                      Budget Reconciliation Act (COBRA) as amended.
Participating Providers may collect any difference between
their billed charges and this Plan's payment, from the sec-           In accordance with the Consolidated Omnibus Budget Rec-
ondary carrier(s).                                                    onciliation Act (COBRA) as amended, a Member will be
                                                                      entitled to elect to continue group coverage under this Plan
If this Plan is the secondary carrier in the order of pay-
                                                                      if the Member would otherwise lose coverage because of a
ments, and the Claims Administrator is notified that there is
                                                                      Qualifying Event that occurs while the Employer is subject
a dispute as to which plan is primary, or that the primary
                                                                      to the continuation of group coverage provisions of CO-
plan has not paid within a reasonable period of time, this
                                                                      BRA. The benefits under the group continuation of cover-
Plan will pay the benefits that would be due as if it were the
                                                                      age will be identical to the benefits that would be provided
primary plan, provided that the covered Member (1) assigns
                                                                      to the Member if the Qualifying Event had not occurred
to the Claims Administrator the right to receive benefits
                                                                      (including any changes in such coverage).
from the other plan to the extent of the difference between
the benefits which the Claims Administrator actually pays             Under COBRA, a Member is entitled to benefits if at the
and the amount that the Claims Administrator would have               time of the qualifying event such Member is entitled to
been obligated to pay as the secondary plan, (2) agrees to            Medicare or has coverage under another group health plan.
cooperate fully with the Claims Administrator in obtaining            However, if Medicare entitlement or coverage under an-
payment of benefits from the other plan, and (3) allows the           other group health plan arises after COBRA coverage be-
Claims Administrator to obtain confirmation from the other            gins, it will cease.
plan that the benefits which are claimed have not previously
been paid.


                                                                 41
Qualifying Event                                                       have a COBRA administrator) of the Participant’s death,
                                                                       termination, or reduction of hours of employment, the Par-
A Qualifying Event is defined as a loss of coverage as a
                                                                       ticipant’s Medicare entitlement or the Employer’s filing for
result of any one of the following occurrences.
                                                                       reorganization under Title XI, United States Code.
1.   With respect to the Participant:
                                                                       When the COBRA administrator is notified that a Qualify-
     a.   the termination of employment (other than by rea-            ing Event has occurred, the COBRA administrator will,
          son of gross misconduct); or                                 within 14 days, provide written notice to the Member by
                                                                       first class mail of the Member’s right to continue group
     b.   the reduction of hours of employment to less than            coverage under this Plan. The Member must then notify the
          the number of hours required for eligibility.                COBRA administrator within 60 days of the later of (1) the
2.   With respect to the Dependent spouse or Dependent                 date of the notice of the Member’s right to continue group
     Domestic Partner* and Dependent children (children                coverage or (2) the date coverage terminates due to the
     born to or placed for adoption with the Participant or            Qualifying Event.
     Domestic Partner during a COBRA continuation period               If the Member does not notify the COBRA administrator
     may be immediately added as Dependents, provided                  within 60 days, the Member’s coverage will terminate on
     the Employer is properly notified of the birth or place-
                                                                       the date the Member would have lost coverage because of
     ment for adoption, and such children are enrolled                 the Qualifying Event.
     within 30 days of the birth or placement for adoption):
     *Note: Domestic Partners and Dependent children of                Duration and Extension
     Domestic Partners cannot elect COBRA on their own,                of Continuation of Group Coverage
     and are only eligible for COBRA if the Participant                In no event will continuation of group coverage under CO-
     elects to enroll.                                                 BRA be extended for more than 3 years from the date the
     a.   the death of the Participant; or                             Qualifying Event has occurred which originally entitled the
                                                                       Member to continue group coverage under this Plan.
     b.   the termination of the Participant’s employment
          (other than by reason of such Participant’s gross            Note: Domestic Partners and Dependent children of Do-
          misconduct); or                                              mestic Partners cannot elect COBRA on their own, and are
                                                                       only eligible for COBRA if the Participant elects to enroll.
     c.   the reduction of the Participant’s hours of em-
          ployment to less than the number of hours required           Payment of Dues
          for eligibility; or                                          Dues for the Member continuing coverage shall be 102 per-
     d.   the divorce or legal separation of the Participant           cent of the applicable group dues rate, except for the Mem-
          from the Dependent spouse or termination of the              ber who is eligible to continue group coverage to 29 months
          domestic partnership; or                                     because of a Social Security disability determination, in
                                                                       which case, the dues for months 19 through 29 shall be 150
     e.   the Participant’s entitlement to benefits under Title        percent of the applicable group dues rate.
          XVIII of the Social Security Act (“Medicare”); or
                                                                       If the Member is contributing to the cost of coverage, the
     f.   a Dependent child’s loss of Dependent status un-             Employer shall be responsible for collecting and submitting
          der this Plan.                                               all dues contributions to the Claims Administrator in the
3.   With respect to a Participant who is covered as a re-             manner and for the period established under this Plan.
     tiree, that retiree’s Dependent spouse and Dependent
                                                                       Effective Date of the Continuation of Coverage
     children, the Employer's filing for reorganization under
     Title XI, United States Code, commencing on or after              The continuation of coverage will begin on the date the
     July 1, 1986.                                                     Member’s coverage under this Plan would otherwise termi-
                                                                       nate due to the occurrence of a Qualifying Event and it will
4.   With respect to any of the above, such other Qualifying
                                                                       continue for up to the applicable period, provided that cov-
     Event as may be added to Title X of COBRA.                        erage is timely elected and so long as dues are timely paid.
Notification of a Qualifying Event                                     Termination of Continuation of Group Coverage
The Member is responsible for notifying the Employer of                The continuation of group coverage will cease if any one of
divorce, legal separation, or a child’s loss of Dependent
                                                                       the following events occurs prior to the expiration of the
status under this Plan, within 60 days of the date of the later        applicable period of continuation of group coverage:
of the Qualifying Event or the date on which coverage
would otherwise terminate under this Plan because of a                 1.   discontinuance of this group health plan (if the Em-
Qualifying Event.                                                           ployer continues to provide any group benefit plan for
                                                                            employees, the Member may be able to continue cov-
The Employer is responsible for notifying its COBRA ad-                     erage with another plan);
ministrator (or Plan administrator if the Employer does not

                                                                  42
2.   failure to timely and fully pay the amount of required            An application and first Dues payment for the individual
     dues to the COBRA administrator or the Employer or                conversion plan must be received by the Claims Adminis-
     to the Claims Administrator as applicable. Coverage               trator within 63 days of the date of termination of your
     will end as of the end of the period for which dues               group coverage. However, if the group plan is replaced by
     were paid;                                                        your Employer with similar coverage under another con-
                                                                       tract within 15 days, transfer to the individual conversion
3.   the Member becomes covered under another group
                                                                       health plan will not be permitted. You will not be permitted
     health plan that does not include a pre-existing condi-
                                                                       to transfer to the individual conversion plan under any of
     tion exclusion or limitation provision that applies to the
                                                                       the following circumstances:
     Member;
                                                                       1.   You failed to pay amounts due the Plan;
4.   the Member becomes entitled to Medicare;
                                                                       2.   You were terminated by the Plan for good cause or for
5.   the Member no longer resides in the Claims Adminis-
                                                                            fraud or misrepresentation;
     trator’s service area;
                                                                       3.   You knowingly furnished incorrect information or oth-
6.   the Member commits fraud or deception in the use of
                                                                            erwise improperly obtained the Benefits of the Plan;
     the Services of this Plan.
                                                                       4.   You are covered or eligible for Medicare;
Continuation of group coverage in accordance with CO-
BRA will not be terminated except as described in this pro-            5.   You are covered or eligible for Hospital, medical or
vision.                                                                     surgical benefits under state or federal law or under any
                                                                            arrangement of coverage for individuals in a group,
CONTINUATION OF GROUP COVERAGE                                              whether insured or self-insured; and,
FOR MEMBERS ON MILITARY LEAVE                                          6.   You are covered for similar benefits under an individ-
                                                                            ual policy or contract.
Continuation of group coverage is available for Members
on military leave if the Member’s Employer is subject to               Benefits or rates of an individual conversion health plan are
the Uniformed Services Employment and Re-employment                    different from those in your group Plan.
Rights Act (USERRA). Members who are planning to en-                   A conversion plan is also available to:
ter the Armed Forces should contact their Employer for
information about their rights under the USERRA. Em-                   1.   Dependents, if the Participant dies;
ployers are responsible to ensure compliance with this act             2.   Dependents who marry or exceed the maximum age for
and other state and federal laws regarding leaves of absence                Dependent coverage under the group Plan;
including the California Family Rights Act, the Family and
Medical Leave Act, and Labor Code requirements for                     3.   Dependents, if the Participant enters military service;
Medical Disability.                                                    4.   Spouse or Domestic Partner of a Participant if their
Availability of the Claims Administrator’s                                  marriage or domestic partnership has been terminated;
Individual Plans                                                       5.   Dependents, when continuation of coverage under
The Claims Administrator's Individual Plans described be-                   COBRA expires, or is terminated.
low may be available to Members whose group coverage or                When a Dependent reaches the limiting age for coverage as
COBRA coverage is terminated or expires while covered                  a Dependent, or if a Dependent becomes ineligible for any
under this group Plan.                                                 of the other reasons given above, it is your responsibility to
                                                                       inform the Claims Administrator. Upon receiving notifica-
INDIVIDUAL CONVERSION PLAN                                             tion, the Claims Administrator will offer such Dependent an
                                                                       individual conversion plan for purposes of continuous cov-
Continued Protection                                                   erage.
Regardless of age, physical condition, or employment
                                                                       Guaranteed Issue Individual Coverage
status, you may continue the Claims Administrator protec-
tion when you retire, leave the job, or become ineligible for          Under the Health Insurance Portability and Accountability
group coverage. If you have held group coverage for three              Act of 1996 (HIPAA, you may be entitled to apply for cer-
or more consecutive months, you and your enrolled De-                  tain of the Claims Administrator’s individual health plans
pendents may apply to transfer to an individual conversion             on a guaranteed issue basis (which means that you will not
plan then being issued by the Claims Administrator.                    be rejected for underwriting reasons if you meet the other
                                                                       eligibility requirements, you live or work in the Claims
Your Employer is solely responsible for notifying you of
                                                                       Administrator’s service area and you agree to pay all re-
the availability, terms, and conditions of the individual con-
                                                                       quired Dues). You may also be eligible to purchase similar
version plan within 15 days of termination of the Plan.
                                                                       coverage on a guaranteed issue basis from any other health
                                                                       plan that sells individual coverage for hospital, medical or


                                                                  43
surgical benefits. Not all the Claims Administrator individ-        When a Benefit specifies a Benefit maximum and
ual plans are available on a guaranteed issue basis under           that Benefit maximum has been reached, the Par-
HIPAA. To be eligible, you must meet the following re-
quirements:
                                                                    ticipant is responsible for any charges above the
                                                                    Benefit maximums.
•   You must have at least 18 or more months of creditable
    coverage.
                                                                    NON-ASSIGNABILITY
•   Your most recent coverage must have been group cov-
                                                                    Coverage or any Benefits of this Plan may not be assigned
    erage (COBRA is considered group coverage for these
                                                                    without the written consent of the Claims Administrator.
    purposes).
                                                                    Possession of an ID card confers no right to Services or
•   You must have elected and exhausted all COBRA cov-              other Benefits of this Plan. To be entitled to Services, the
    erage that is available to you.                                 Member must be a Participant who has been accepted by
                                                                    the Employer and enrolled by the Claims Administrator and
•   You must not be eligible for nor have any other health          who has maintained enrollment under the terms of this Plan.
    insurance coverage, including a group health plan,
    Medicare or Medi-Cal.                                           Participating Providers and Preferred Providers are paid
                                                                    directly by the Claims Administrator. The Member or the
•   You must make application to the Claims Administra-             provider of Service may not request that payment be made
    tor for guaranteed issue coverage within 63 days of the         directly to any other party.
    date of termination from the group plan.
                                                                    If the Member receives Services from a Non-Preferred Pro-
If you elect Conversion Coverage or other the Claims Ad-            vider, the Participant is responsible for payment of the en-
ministrator individual plans, you will waive your right to          tire bill to the Non-Preferred Provider.
this guaranteed issue coverage. For more information, con-
tact the Claims Administrator Customer Service representa-          PLAN INTERPRETATION
tive 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
NON-PAYMENT BY THE CLAIMS ADMINISTRATOR                             benefit of all Members entitled to receive Benefits under
                                                                    this Plan.
In accordance with the Claims Administrator's
established policies, and by statute, every contract                CONFIDENTIALITY OF PERSONAL AND HEALTH
between the Claims Administrator and its Partici-                   INFORMATION
pating Providers and Preferred Providers stipu-
                                                                    The Claims Administrator protects the confidential-
lates that the Participant shall not be responsible
                                                                    ity/privacy of your personal and health information. Per-
to the Participating Provider or Preferred Provider                 sonal and health information includes both medical infor-
for compensation for any Services to the extent                     mation and individually identifiable information, such as
that they are provided in the Participant's Plan.                   your name, address, telephone number, or social security
Participating Providers and Preferred Providers                     number. the Claims Administrator will not disclose this
                                                                    information without your authorization, except as permitted
have agreed to accept the Plan’s payment as pay-
                                                                    by law.
ment-in-full for covered Services, except for the
Deductibles, Copayments, amounts in excess of                       A STATEMENT DESCRIBING the CLAIMS
specified Benefit maximums, or as provided un-                      ADMINISTRATOR'S POLICIES AND PRO-
der the Exception for Other Coverage provision                      CEDURES FOR PRESERVING THE CONFI-
and the Reductions section regarding Third Party                    DENTIALITY OF MEDICAL RECORDS IS
Liability.                                                          AVAILABLE AND WILL BE FURNISHED TO
                                                                    YOU UPON REQUEST.
If Services are provided by a Non-Preferred Pro-
vider, the Participant is responsible for the entire                The Claims Administrator’s policies and procedures regard-
                                                                    ing our confidentiality/privacy practices are contained in
bill except for Medically Necessary emergency                       the “Notice of Privacy Practices”, which you may obtain
care.                                                               either by calling the Customer Service Department at the
                                                                    number listed on the back of this booklet, or by accessing



                                                               44
the Claims Administrator’s internet site located at                  Note: The Claims Administrator has established a proce-
http://www.blueshieldca.com and printing a copy.                     dure for our Participants and Dependents to request an ex-
                                                                     pedited decision. A Member, Physician, or representative
If you are concerned that the Claims Administrator may
                                                                     of a Member may request an expedited decision when the
have violated your confidentiality/privacy rights, or you
                                                                     routine decision making process might seriously jeopardize
disagree with a decision we made about access to your per-
                                                                     the life or health of a Member, or when the Member is ex-
sonal and health information, you may contact us at:
                                                                     periencing severe pain. The Claims Administrator shall
Correspondence Address:                                              make a decision and notify the Member and Physician as
                                                                     soon as possible to accommodate the Member’s condition
Blue Shield of California Privacy Official                           not to exceed 72 hours following the receipt of the request.
P.O. Box 272540                                                      An expedited decision may involve admissions, continued
Chico, CA 95927-2540                                                 stay or other healthcare Services. If you would like addi-
Toll-Free Telephone:                                                 tional information regarding the expedited decision process,
                                                                     or if you believe your particular situation qualifies for an
1-888-266-8080                                                       expedited decision, please contact our Customer Service
Email Address:                                                       Department at the number provided on the last page of this
                                                                     booklet.
blueshieldca_privacy@blueshieldca.com

ACCESS TO INFORMATION                                                SETTLEMENT OF DISPUTES
The Claims Administrator may need information from                   Request for Initial Appeal
medical providers, from other carriers or other entities, or         If a claim has been denied in whole or in part by the Claims
from you, in order to administer benefits and eligibility            Administrator, the Participant may request the Customer
provisions of this Plan. You agree that any provider or en-          Service Department of the Claims Administrator to give
tity can disclose to the Claims Administrator that informa-          further consideration to the claim, by telephone or written
tion that is reasonably needed by the Claims Administrator.          request including any additional information that would
You agree to assist the Claims Administrator in obtaining            affect the processing of the claim. The Claims Administra-
this information, if needed, (including signing any neces-           tor will acknowledge receipt of a written grievance within 5
sary authorizations) and to cooperate by providing the               calendar days.
Claims Administrator with information in your possession.
Failure to assist the Claims Administrator in obtaining nec-         The Claims Administrator reserves the right to refer appro-
essary information or refusal to provide information rea-            priate matters to a Peer Review committee of the appropri-
sonably needed may result in the delay or denial of benefits         ate local medical or dental society or of the California
until the necessary information is received. Any informa-            Medical or Dental Association which is appropriate for
tion received for this purpose by the Claims Administrator           such review.
will be maintained as confidential and will not be disclosed         The grievance system allows Participants to file grievances
without your consent, except as otherwise permitted by law.          for at least 180 days following any incident or action that is
                                                                     the subject of the enrollee’s dissatisfaction. Appeals are
INDEPENDENT CONTRACTORS                                              resolved in writing, within 30 days of the date of receipt.
Providers are neither agents nor employees of the Plan but           Final Appeal
are independent contractors. In no instance shall the Plan be
liable for the negligence, wrongful acts, or omissions of any        If the Participant is dissatisfied with the administrative re-
person receiving or providing Services, including any Phy-           view determination by the Claims Administrator, the de-
sician, Hospital, or other provider or their employees.              termination may be appealed in writing to the Claims Ad-
                                                                     ministrator within 60 days after notice of the administrative
                                                                     review determination. Such written request shall contain
CUSTOMER SERVICE                                                     any additional information which the Participant wishes the
If you have a question about Services, providers, Benefits,          Claims Administrator to consider. The Claims Administra-
how to use this Plan, or concerns regarding the quality of           tor shall notify the Participant in writing of the results of its
care or access to care that you have experienced, you may            review and the specific basis therefore. In the event the
contact the Customer Service Department as noted on the              Claims Administrator finds all or part of the appeal to be
last page of this booklet.                                           valid, the Claims Administrator, on behalf of the Employer,
                                                                     shall reimburse the Participant for those expenses which the
The hearing impaired may contact the Customer Service                Claim Administrator allowed as a result of its review of the
Department through the Claims Administrator’s toll-free              appeal. The Claims Administrator's determination shall be
TTY number, 1-800-241-1823.                                          final and binding on all parties. With respect to any other
Customer Service can answer many questions over the tele-            determination made by the Plan or the Claims Administra-
phone.

                                                                45
tor pursuant to the Plan Agreement, the Plan’s determina-                   tion, and Outpatient clinics not MD owned; portable X-
tion shall be final an binding on all parties.                              ray companies; lay-owned independent laboratories;
                                                                            blood banks; speech and hearing centers; dental labora-
DEFINITIONS                                                                 tories; dental supply companies; nursing homes; ambu-
                                                                            lance companies; Easter Seal Society; American Can-
                                                                            cer Society, and Catholic Charities.
PLAN PROVIDER DEFINITIONS
                                                                       Outpatient Facility — a licensed facility, not a Physician's
Whenever any of the following terms are capitalized in this            office or Hospital, that provides medical and/or surgical ser-
booklet, they will have the meaning stated below:                      vices on an Outpatient basis.
Alternate Care Services Providers — Durable Medical                    Participating Ambulatory Surgery Center — an Outpa-
Equipment suppliers, individual certified orthotists, pros-            tient surgery facility which:
thetists and prosthetist-orthotists.
                                                                       1.   is either licensed by the state of California as an ambu-
Doctor of Medicine — a licensed Medical Doctor (M.D.) or                    latory surgery center or is a licensed facility accredited
Doctor of Osteopathic Medicine (D.O.).                                      by an ambulatory surgery center accrediting body; and,
Hospice or Hospice Agency – an entity which provides                   2.   provides services as a free-standing ambulatory surgery
Hospice services to Terminally Ill persons and holds a li-                  center which is licensed separately and bills separately
cense, currently in effect as a Hospice which has Medicare                  from a Hospital and is not otherwise affiliated with a
certification.                                                              Hospital; and,
Hospital —                                                             3.   has contracted with the Claims Administrator to pro-
1.   a licensed institution primarily engaged in providing,                 vide Services on an Outpatient basis.
     for compensation from patients, medical, diagnostic               Participating Home Health Care and Home Infusion
     and surgical facilities for care and treatment of sick and        Agency — an agency which has contracted with the Claims
     injured persons on an Inpatient basis, under the super-           Administrator to furnish services and accept reimbursement
     vision of an organized medical staff, and which pro-              at negotiated rates, and which has been designated as a Par-
     vides 24 hour a day nursing service by registered                 ticipating Home Health Care and Home Infusion agency by
     nurses. A facility which is principally a rest home or            the Claims Administrator. (See Non-Participating Home
     nursing home or home for the aged is not included.                Health Care and Home Infusion agency definition above.)
2.   a psychiatric Hospital accredited by the Joint Commis-            Participating Hospice or Participating Hospice Agency –
     sion on Accreditation of Healthcare Organizations.                an entity which: 1) provides Hospice services to Terminally
Non-Participating Home Health Care and Home Infu-                      Ill Members and holds a license, currently in effect, as a
sion agency — an agency which has not contracted with                  Hospice pursuant to Health and Safety Code Section 1747,
the Claims Administrator and whose services are not cov-               or a home health agency licensed pursuant to Health and
ered under the Plan.                                                   Safety Code Sections 1726 and 1747.1 which has Medicare
                                                                       certification and 2) has either contracted with the Claims
Non-Participating/Non-Preferred Providers — any pro-                   Administrator or has received prior approval from the
vider who has not contracted with the Claims Administrator             Claims Administrator to provide Hospice Service Benefits
to accept the Claims Administrator's payment, plus any                 pursuant to the California Health and Safety Code Section
applicable Deductible, Copayment or amounts in excess of               1368.2.
specified Benefit maximums, as payment-in-full for cov-
ered Services.       Services provided by a Non-                       Participating Physician — a selected Physician or a Physi-
Participating/Non-Preferred Provider are not covered ex-               cian Member that has contracted with the Claims Adminis-
cept for Medically Necessary Covered Services received for             trator to furnish Services and to accept the Claims Adminis-
emergency or urgent care.                                              trator's payment, plus applicable Deductibles and Copay-
                                                                       ments, as payment-in-full for covered Services, except as
Other Providers —                                                      provided under the Payment and Participant Copayment pro-
1.   Independent Practitioners — licensed vocational                   vision in this booklet.
     nurses; licensed practical nurses; registered nurses; li-         Participating Provider — a Physician, a Hospital, an Am-
     censed psychiatric nurses; registered dieticians; certi-          bulatory Surgery Center, an Alternate Care Services Pro-
     fied nurse midwives; licensed occupational therapists;            vider, a Certified Registered Nurse Anesthetist, or a Home
     certificated acupuncturists; certified respiratory thera-         Health Care and Home Infusion agency that has contracted
     pists; enterostomal therapists; licensed speech thera-            with the Claims Administrator to furnish Services and to
     pists or pathologists; dental technicians; and lab techni-        accept the Claims Administrator's payment, plus applicable
     cians.                                                            Deductibles and Copayments, as payment in full for cov-
2.   Healthcare Organizations — nurses registry; licensed              ered Services.
     mental health, freestanding public health, rehabilita-

                                                                  46
Note: This definition does not apply to Hospice Program                    contract will be accepted as payment in full for the Ser-
Services. For Participating Providers for Hospice Program                  vices rendered; or
Services, see the Participating Hospice or Participating
                                                                      2.   For a non-participating provider anywhere within or
Hospice Agency definitions above.
                                                                           outside of the United States who provides Emergency
Physician — a licensed Doctor of Medicine, clinical psy-                   Services:
chologist, research psychoanalyst, dentist, licensed clinical
                                                                           a.   Physicians and Hospitals – the Reasonable and
social worker, optometrist, chiropractor, podiatrist, audi-
                                                                                Customary Charge;
ologist, registered physical therapist, or licensed marriage
and family therapist.                                                      b.   All other providers – the provider’s billed charge
                                                                                for covered Services, unless the provider and the
Physician Member — a Doctor of Medicine who has en-
                                                                                local Blue Cross and/or Blue Shield have agreed
rolled with the Claims Administrator as a Physician Mem-
                                                                                upon some other amount; or
ber.
                                                                      3.   For a non-participating provider in California, includ-
Preferred Dialysis Center — a dialysis services facility
                                                                           ing an Other Provider, who provides Services on other
which has contracted with the Claims Administrator to pro-
                                                                           than an emergency basis, the Participant is responsible
vide dialysis Services on an Outpatient basis and accept
                                                                           for the entire bill; or
reimbursement at negotiated rates.
                                                                      4.   For a provider anywhere, other than in California,
Preferred Hospital — a Hospital under contract to the
                                                                           within or outside of the United States, which has a con-
Claims Administrator which has agreed to furnish Services
                                                                           tract with the local Blue Cross and/or Blue Shield plan,
and accept reimbursement at negotiated rates, and which
                                                                           the amount that the provider and the local Blue Cross
has been designated as a Preferred Hospital by the Claims
                                                                           and/or Blue Shield plan have agreed by contract will be
Administrator.
                                                                           accepted as payment in full for service rendered; or
Preferred Provider — a Physician Member, Preferred
                                                                      5.   For a non-participating provider (i.e., that does not
Hospital, Preferred Dialysis Center, or Participating Pro-
                                                                           contract with a local Blue Cross and/or Blue Shield
vider.
                                                                           plan) anywhere, other than in California, within or out-
Skilled Nursing Facility — a facility with a valid license                 side of the United States, who provides Services on
issued by the California Department of Health Services as a                other than an emergency basis, the Participant is re-
Skilled Nursing Facility or any similar institution licensed               sponsible for the entire bill.
under the laws of any other state, territory, or foreign coun-
                                                                      Benefits (Services) — those Services which a Member is
try.
                                                                      entitled to receive pursuant to the Plan Document.
ALL OTHER DEFINITIONS                                                 Calendar Year — a period beginning on January 1 of any
                                                                      year and terminating on January 1 of the following year.
Whenever any of the following terms are capitalized in this
booklet, they will have the meaning stated below:                     Chronic Care — care (different from Acute Care) furnished
                                                                      to treat an illness, injury or condition, which does not require
Accidental Injury — definite trauma resulting from a sud-             hospitalization (although confinement in a lesser facility may
den, unexpected and unplanned event, occurring by chance,             be appropriate), which may be expected to be of long dura-
caused by an independent, external source.                            tion without any reasonably predictable date of termination,
Activities of Daily Living (ADL) — mobility skills re-                and which may be marked by recurrences requiring continu-
quired for independence in normal everyday living. Recrea-            ous or periodic care as necessary.
tional, leisure, or sports activities are not included.               Claims Administrator — the claims payor designated by
Acute Care — care rendered in the course of treating an               the Employer to adjudicate claims and provide other ser-
illness, injury or condition marked by a sudden onset or              vices as mutually agreed. Blue Shield of California has
change of status requiring prompt attention, which may                been designated the Claims Administrator.
include hospitalization, but which is of limited duration and         Close Relative — the spouse, Domestic Partner, children,
which is not expected to last indefinitely.                           brothers, sisters, or parents of a covered Member.
Allowable Amount — the Claims Administrator Allow-                    Copayment — the amount that a Member is required to
ance (as defined below) for the Service (or Services) ren-            pay for specific Covered Services after meeting any appli-
dered, or the provider’s billed charge, whichever is less.            cable Deductible.
The Claims Administrator Allowance, unless otherwise
specified for a particular service elsewhere in this booklet,         Cosmetic Surgery — surgery that is performed to alter or
is:                                                                   reshape normal structures of the body to improve appear-
                                                                      ance.
1.   For a Participating Provider, the amount that the Pro-
     vider and the Claims Administrator have agreed by


                                                                 47
Covered Services (Benefits) — those Services which a                              ment of age 19). Full-time student means a De-
Member is entitled to receive pursuant to the terms of the                        pendent must be enrolled in a college, university,
Plan Document.                                                                    vocational, or technical school for a minimum of
                                                                                  12 units as an undergraduate, or 6 units as a gradu-
Custodial or Maintenance Care — care furnished in the
                                                                                  ate student;
home primarily for supervisory care or supportive services,
or in a facility primarily to provide room and board (which             and who has been enrolled and accepted by the Claims
may or may not include nursing care, training in personal               Administrator as a Dependent and has maintained participa-
hygiene and other forms of self care and/or supervisory care            tion in accordance with the Claims Administrator Plan.
by a Physician) or care furnished to a Member who is men-
                                                                                  *Note: For approved full-time students as de-
tally or physically disabled, and
                                                                                  scribed in 3.d. above:
1.   who is not under specific medical, surgical or psychiat-
                                                                                  (1) any break in the school calendar shall not
     ric treatment to reduce the disability to the extent nec-
                                                                                      disqualify the Dependent from coverage;
     essary to enable the patient to live outside an institution
     providing care; or                                                           (2) the coverage for a Dependent on an approved
                                                                                      medical leave of absence will not be termi-
2.   when, despite medical, surgical or psychiatric treat-
                                                                                      nated for a period of 12 months or the date
     ment, there is no reasonable likelihood that the disabil-
                                                                                      on which the coverage should terminate per
     ity will be so reduced.
                                                                                      the provisions of the Plan whichever comes
Deductible – the Calendar Year amount which you must                                  first;
pay for specific Covered Services that are a Benefit of the
                                                                                  (3) for a medical leave of absence from school to
Plan before you become entitled to receive certain Benefit
                                                                                      be approved by the Claims Administrator,
payments from the Plan for those Services.
                                                                                      the Member must submit documentation or
Dependent —                                                                           certification of the medical necessity of the
                                                                                      leave. This submission should be sent to the
1.   a Participant’s legally married spouse who is:
                                                                                      Claims Administrator at least 30 days prior
     a.    not covered for Benefits as a Participant; and                             to the first day of the leave or, if not possible,
                                                                                      must be sent no later than 30 days after the
     b.    not legally separated from the Participant;                                leave commences.
     or,
                                                                        4.   If coverage for a Dependent child would be terminated
2.   a Participant’s Domestic Partner who is not covered for                 because of the attainment of age 19 (or age 23, if De-
     Benefits as a Participant;                                              pendent has been a full-time student), and the Depend-
                                                                             ent child is disabled, Benefits for such Dependent will
     or,                                                                     be continued upon the following conditions:
3.   a Participant’s, spouse’s, or Domestic Partner’s unmar-                 a.   the child must be chiefly dependent upon the Par-
     ried child or child who is not one of the partners in a                      ticipant, spouse, or Domestic Partner for support
     domestic partnership (including any stepchild or child                       and maintenance;
     placed for adoption or any other child for whom the
     Participant, spouse, or Domestic Partner has been ap-                   b.   the Participant, spouse, or Domestic Partner sub-
     pointed as a non-temporary legal guardian by a court of                      mits to the Claims Administrator a Physician's
     appropriate legal jurisdiction) who is not covered for                       written certification of disability within 60 days
     Benefits as a Participant and who is:                                        from the date of the Employer's or the Claims
                                                                                  Administrator's request; and
     a.    primarily dependent upon the Participant, spouse,
           or Domestic Partner for support and maintenance;                  c.   thereafter, certification of continuing disability and
           or                                                                     dependency from a Physician is submitted to the
                                                                                  Claims Administrator on the following schedule:
     b.    dependent upon the Participant, spouse, or Domes-
           tic Partner for medical support pursuant to a court                    (1) within 24 months after the month when the
           order; and is                                                              Dependent would otherwise have been termi-
                                                                                      nated; and
     c.    less than 19 years of age; or
                                                                                  (2) annually thereafter on the same month when
     d.    less than 23 years of age if enrolled as a full-time                       certification was made in accordance with
           student and if proof of student status is submitted                        item (1) above. In no event will coverage be
           to and received by the Claims Administrator.*                              continued beyond the date when the Depend-
           This item d. does not apply to a child of a legal                          ent child becomes ineligible for coverage un-
           guardian unless a court has specifically ordered                           der this Plan for any reason other than attained
           that the guardianship continue beyond the attain-                          age.


                                                                   48
Domestic Partner — an individual who is personally re-               device usage, or supplies which are not recognized in ac-
lated to the Participant by a domestic partnership that meets        cordance with generally accepted professional medical
the following requirements:                                          standards as being safe and effective for use in the treat-
                                                                     ment of the illness, injury, or condition at issue. Services
1.   Domestic partners are two adults who have chosen to             which require approval by the Federal government or any
     share one another’s lives in an intimate and committed          agency thereof, or by any State government agency, prior to
     relationship of mutual caring;                                  use and where such approval has not been granted at the
                                                                     time the services or supplies were rendered, shall be con-
2.   Both persons have filed a Declaration of Domestic               sidered experimental or investigational in nature. Services
     Partnership with the California Secretary of State.             or supplies which themselves are not approved or recog-
     California state registration is limited to same sex do-        nized in accordance with accepted professional medical
     mestic partners and only those opposite sex partners            standards, but nevertheless are authorized by law or by a
     where one partner is at least 62 and eligible for Social        government agency for use in testing, trials, or other studies
     Security based on age.                                          on human patients, shall be considered experimental or in-
                                                                     vestigational in nature.
The domestic partnership is deemed created on the date the
Declaration of Domestic Partnership is filed with the Cali-          Family — the Participant and all enrolled Dependents.
fornia Secretary of State.                                           Family Coverage — Coverage provided for 2 or more
Domiciliary Care — care provided in a Hospital or other              Members, as defined herein.
licensed facility because care in the patient's home is not
                                                                     Incurred — a charge will be considered to be “Incurred”
available or is unsuitable.                                          on the date the particular service or supply which gives rise
Durable Medical Equipment — equipment designed for                   to it is provided or obtained.
repeated use which is medically necessary to treat an illness
                                                                     Individual (Self-only) Coverage — Coverage provided for
or injury, to improve the functioning of a malformed body            only one Participant, as defined herein.
member, or to prevent further deterioration of the patient's
medical condition. Durable Medical Equipment includes                Infertility — either (1) the presence of a demonstrated bod-
items such as wheelchairs, Hospital beds, respirators, and           ily malfunction recognized by a licensed Doctor of Medi-
other items that the Claims Administrator determines are             cine as a cause of Infertility, or (2) because of a demon-
Durable Medical Equipment.                                           strated bodily malfunction, the inability to conceive a preg-
                                                                     nancy or to carry a pregnancy to a live birth after a year or
Emergency Services — services provided for an unex-                  more of regular sexual relations without contraception, or
pected medical condition, including a psychiatric emer-              (3) because of the inability to conceive a pregnancy after
gency medical condition, manifesting itself by acute symp-           six cycles of artificial insemination supervised by a Physi-
toms of sufficient severity (including severe pain) that the         cian. These initial six cycles are not a benefit of this Plan.
absence of immediate medical attention could reasonably
be expected to result in any of the following:                       Inpatient — an individual who has been admitted to a Hos-
                                                                     pital as a registered bed patient and is receiving services un-
1.   placing the patient's health in serious jeopardy;               der the direction of a Physician.
2.   serious impairment to bodily functions;
                                                                     Late Enrollee — an eligible Employee or Dependent who
3.   serious dysfunction of any bodily organ or part.                has declined enrollment in this Plan at the time of the initial
                                                                     enrollment period, and who subsequently requests enroll-
Employee — an individual who, by meeting the Plan’s                  ment in this Plan; provided that the initial enrollment period
eligibility requirements for employees, is allowed to choose         shall be a period of at least 30 days. However, an eligible
membership under this Plan for himself or herself and his or         Employee or Dependent shall not be considered a Late En-
her eligible Dependents.                                             rollee if any of the following paragraphs (1.), (2.), (3.), (4.),
Employer — a public agency that has at least 2 employees             (5.), (6.) or (7.) is applicable:
and that is actively engaged in business or service, in which        1.   The eligible Employee or Dependent meets all of the
a bona fide employer-employee relationship exists, in                     following requirements of (a.), (b.), (c.) and (d.):
which the majority of employees were employed within this
state, and which was not formed primarily for purposes of                 a.   The Employee or Dependent was covered under
buying health care coverage or insurance.                                      another employer health benefit plan at the time he
                                                                               or she was offered enrollment under this Plan; and
Enrollment Date — the first day of coverage, or if there is
a waiting period, the first day of the waiting period (typi-              b.   The Employee or Dependent certified, at the time
cally, date of hire).                                                          of the initial enrollment, that coverage under an-
                                                                               other employer health benefit plan was the reason
Experimental or Investigational in Nature — any treat-                         for declining enrollment, provided that, if he or she
ment, therapy, procedure, drug or drug usage, facility or                      was covered under another employer health plan,
facility usage, equipment or equipment usage, device or                        he or she was given the opportunity to make the

                                                                49
          certification required and was notified that failure               within 60 days of the notice of eligibility for these pre-
          to do so could result in later treatment as a Late                 mium assistance programs; or
          Enrollee; and
                                                                        7.   For eligible Employees who decline coverage during
     c.   The Employee or Dependent has lost or will lose                    the initial enrollment period and subsequently acquire
          coverage under another employer health benefit                     Dependents through marriage, establishment of domes-
          plan as a result of termination of his or her em-                  tic partnership, birth, or placement for adoption, and
          ployment or of the individual through whom he or                   who enroll for coverage for themselves and their De-
          she was covered as a Dependent, change in his or                   pendents within 31 days from the date of marriage, es-
          her employment status or of the individual through                 tablishment of domestic partnership, birth, or place-
          whom he or she was covered as a Dependent, ter-                    ment for adoption.
          mination of the other plan’s coverage, exhaustion
                                                                        Medical Necessity (Medically Necessary) —
          of COBRA continuation coverage, cessation of an
          employer’s contribution toward his or her cover-              The Benefits of this Plan are provided only for Services
          age, death of the individual through whom he or               which are medically necessary.
          she was covered as a Dependent, or legal separa-
                                                                        1.   Services which are medically necessary include only
          tion, divorce or termination of a domestic partner-
          ship; and                                                          those which have been established as safe and effec-
                                                                             tive, are furnished under generally accepted profes-
     d.   The Employee or Dependent requests enrollment                      sional standards to treat illness, injury or medical con-
          within 31 days after termination of coverage or                    dition, and which, as determined by the Claims Admin-
          employer contribution toward coverage provided                     istrator, are:
          under another employer health benefit plan; or
                                                                             a.   consistent with the Claims Administrator medical
2.   The Employer offers multiple health benefit plans and                        policy;
     the eligible Employee elects this Plan during an open
     enrollment period; or                                                   b.   consistent with the symptoms or diagnosis;
                                                                             c.   not furnished primarily for the convenience of the
3.   A court has ordered that coverage be provided for a
     spouse or Domestic Partner or minor child under a cov-                       patient, the attending Physician or other provider;
     ered Employee’s health benefit Plan. The health Plan                         and
     shall enroll a Dependent child within 31 days of pres-                  d.   furnished at the most appropriate level which can
     entation of a court order by the district attorney, or                       be provided safely and effectively to the patient.
     upon presentation of a court order or request by a cus-
     todial party, as described in Section 3751.5 of the Fam-           2.   If there are two or more medically necessary services
     ily Code; or                                                            that may be provided for the illness, injury or medical
                                                                             condition, the Claims Administrator will provide bene-
4.   For eligible Employees or Dependents who fail to elect                  fits based on the most cost-effective service.
     coverage in this Plan during their initial enrollment pe-
     riod, the Plan cannot produce a written statement from             3.   Hospital Inpatient Services which are medically neces-
     the Employer stating that prior to declining coverage,                  sary include only those Services which satisfy the
     the Employee or Dependent, or the individual through                    above requirements, require the acute bed-patient
     whom he or she was eligible to be covered as a De-                      (overnight) setting, and which could not have been
     pendent, was provided with and signed acknowledg-                       provided in the Physician's office, the Outpatient de-
     ment of a Refusal of Personal Coverage form specify-                    partment of a Hospital, or in another lesser facility
     ing that failure to elect coverage during the initial en-               without adversely affecting the patient's condition or
     rollment period permits the Plan to impose, at the time                 the quality of medical care rendered. Inpatient services
     of his or her later decision to elect coverage, an exclu-               not medically necessary include hospitalization:
     sion from coverage for a period of 12 months, unless                    a.   for diagnostic studies that could have been pro-
     he or she meets the criteria specified in paragraphs (1.),                   vided on an Outpatient basis;
     (2.) or (3.) above; or
                                                                             b.   for medical observation or evaluation;
5.   For eligible Employees or Dependents who were eligi-
     ble for coverage under the Healthy Families Program                     c.   for personal comfort;
     or Medi-Cal and whose coverage is terminated as a re-                   d.   in a pain management center to treat or cure
     sult of the loss of such eligibility, provided that enroll-                  chronic pain; and
     ment is requested no later than 60 days after the termi-
     nation of coverage; or                                                  e.   for Inpatient Rehabilitation that can be provided
                                                                                  on an Outpatient basis.
6.   For eligible Employees or Dependents who are eligible
     for the Healthy Families Program or the Medi-Cal pre-              4.   The Claims Administrator reserves the right to review
     mium assistance program and who request enrollment                      all claims to determine whether services are medically


                                                                   50
     necessary, and may use the services of Physician con-               Plan — the Comprehensive Preferred Medical Benefit Plan
     sultants, peer review committees of professional socie-             for eligible Employees of the Employer.
     ties or Hospitals, and other consultants.
                                                                         Plan Sponsor — is the designated party that sets up a
Member — either a Participant or Dependent.                              healthcare plan for the benefit of the Employer’s Employ-
                                                                         ees. The responsibilities of the Plan Sponsor include de-
Mental Health Condition — for the purposes of this Plan,
                                                                         termining membership parameters, investment choices and
means those conditions listed in the “Diagnostic & Statisti-
                                                                         providing contribution payments.
cal Manual of Mental Disorders Version IV” (DSM4), ex-
cept as stated herein, and no other conditions. Mental                   Program Administrator — CSAC Excess Insurance
Health Conditions include Severe Mental Illnesses and Se-                Authority.
rious Emotional Disturbances of a Child, but do not include
                                                                         Prosthesis (Prosthetics) — an artificial part, appliance or
any services relating to the following:
                                                                         device used to replace or augment a missing or impaired
1.   Diagnosis or treatment of Substance Abuse Conditions;               part of the body.
2.   Diagnosis or treatment of conditions represented by V               Reasonable and Customary Charge — in California: The
     Codes in DSM4;                                                      lower of (1) the provider’s billed charge, or (2) the amount
                                                                         determined by the Claims Administrator to be the reason-
3.   Diagnosis or treatment of any conditions listed in
                                                                         able and customary value for the services rendered by a
     DSM4 with the following codes:
                                                                         non-Plan Provider based on statistical information that is
     294.8, 294.9, 302.80 through 302.90, 307.0, 307.3,                  updated at least annually and considers many factors in-
     307.9, 312.30 through 312.34, 313.9, 315.2, 315.39                  cluding, but not limited to, the provider’s training and ex-
     through 316.0.                                                      perience, and the geographic area where the services are
                                                                         rendered; outside of California: The lower of (1) the pro-
Mental Health Services — Services provided to treat a
                                                                         vider’s billed charge, or, (2) the amount, if any, established
Mental Health Condition.                                                 by the laws of the state to be paid for Emergency Services.
Occupational Therapy — treatment under the direction of                  Reconstructive Surgery — surgery to correct or repair
a Doctor of Medicine and provided by a certified occupa-
                                                                         abnormal structures of the body caused by congenital de-
tional therapist, utilizing arts, crafts, or specific training in        fects, developmental abnormalities, trauma, infection, tu-
daily living skills, to improve and maintain a patient’s abil-           mors, or disease to do either of the following: 1) to im-
ity to function.
                                                                         prove function, or 2) to create a normal appearance to the
Open Enrollment Period — that period of time set forth in                extent possible.
the plan document during which eligible employees and                    Rehabilitation — Inpatient or Outpatient care furnished
their Dependents may transfer from another health benefit                primarily to restore an individual’s ability to function as
plan sponsored by the employer to the Preferred Plan.                    normally as possible after a disabling illness or injury. Re-
Orthosis (Orthotics) — an orthopedic appliance or appara-                habilitation Services may consist of Physical Therapy, Oc-
tus used to support, align, prevent or correct deformities, or           cupational Therapy, and/or Respiratory Therapy and are
to improve the function of movable body parts.                           provided with the expectation that the patient has restora-
                                                                         tive potential. Benefits for Speech Therapy are described in
Outpatient — an individual receiving services but not as                 the section on Speech Therapy Benefits. Rehabilitation
an Inpatient.                                                            Services will be provided for as long as continued treatment
Participant — an Employee who has been accepted by the                   is Medically Necessary pursuant to the treatment plan.
Employer and enrolled by the Claims Administrator as a                   Residential Care — services provided in a facility or a
Participant and who has maintained enrollment in accor-                  free-standing residential treatment center that provides
dance with this Plan.                                                    overnight/extended-stay services for Members who do not
Participating Employer — a Participating Employer is a                   qualify for Acute Care or Skilled Nursing Services.
California city or county government. Specific qualifica-                Respiratory Therapy — treatment, under the direction of
tions of a Participating Employer are stipulated in the par-             a Doctor of Medicine and provided by a certified respira-
ticipation agreement.                                                    tory therapist, to preserve or improve a patient’s pulmonary
Physical Therapy — treatment provided by a Doctor of                     function.
Medicine or under the direction of a Doctor of Medicine                  Serious Emotional Disturbances of a Child — refers to
when provided by a registered physical therapist, certified              individuals who are minors under the age of 18 years who
occupational therapist or licensed doctor of podiatric medi-
cine. Treatment utilizes physical agents and therapeutic                 1.   have one or more mental disorders in the most recent
procedures, such as ultrasound, heat, range of motion test-                   edition of the Diagnostic and Statistical manual of
ing, and massage, to improve a patient’s musculoskeletal,                     Mental Disorders (other than a primary substance use
neuromuscular and respiratory systems.                                        disorder or developmental disorder), that results in be-


                                                                    51
     havior inappropriate for the child’s age according to                  that is specially formulated to have less than one gram
     expected developmental norms, and                                      of protein per serving;
2.   meet the criteria in paragraph (2) of subdivision (a) of          2.   Used in place of normal food products, such as grocery
     Section 5600.3 of the Welfare and Institutions Code.                   store foods, used by the general population.
     This section states that members of this population
                                                                       Speech Therapy — treatment, under the direction of a
     shall meet one or more of the following criteria:
                                                                       Physician and provided by a licensed speech pathologist or
     (a) As a result of the mental disorder the child has              speech therapist, to improve or retrain a patient’s vocal
         substantial impairment in at least two of the fol-            skills which have been impaired by diagnosed illness or
         lowing areas: self-care, school functioning, family           injury.
         relationships, or ability to function in the commu-
                                                                       Subacute Care — skilled nursing or skilled rehabilitation
         nity: and either of the following has occurred: the
                                                                       provided in a Hospital or Skilled Nursing Facility to pa-
         child is at risk of removal from home or has al-
                                                                       tients who require skilled care such as nursing services,
         ready been removed from the home or the mental
                                                                       physical, occupational or speech therapy, a coordinated
         disorder and impairments have been present for
                                                                       program of multiple therapies or who have medical needs
         more than 6 months or are likely to continue for
                                                                       that require daily Registered Nurse monitoring. A facility
         more than one year without treatment;
                                                                       which is primarily a rest home, convalescent facility or
     (b) The child displays one of the following: psychotic            home for the aged is not included.
         features, risk of suicide or risk of violence due to a
                                                                       Substance Abuse Condition — for the purposes of this
         mental disorder.
                                                                       Plan, means any disorders caused by or relating to the re-
Services — includes medically necessary healthcare ser-                current use of alcohol, drugs, and related substances, both
vices and medically necessary supplies furnished incident              legal and illegal, including but not limited to, dependence,
to those services.                                                     intoxication, biological changes and behavioral changes.
Severe Mental Illnesses — conditions with the following                Total Disability (or Totally Disabled) —
diagnoses: schizophrenia, schizo affective disorder, bipolar
                                                                       1.   in the case of an Employee or Member otherwise eligi-
disorder (manic depressive illness), major depressive disor-
                                                                            ble for coverage as an Employee, a disability which
ders, panic disorder, obsessive-compulsive disorder, perva-
                                                                            prevents the individual from working with reasonable
sive developmental disorder or autism, anorexia nervosa,
                                                                            continuity in the individual's customary employment or
bulimia nervosa.
                                                                            in any other employment in which the individual rea-
Special Food Products — a food product which is both of                     sonably might be expected to engage, in view of the
the following:                                                              individual's station in life and physical and mental ca-
                                                                            pacity;
1.   Prescribed by a Physician or nurse practitioner for the
     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 quali-                  the individual from engaging with normal or reason-
     fied health professionals with expertise germane to,                   able continuity in the individual's customary activities
     and experience in the treatment and care of, phenylke-                 or in those in which the individual otherwise reasona-
     tonuria (PKU). It does not include a food that is natu-                bly might be expected to engage, in view of the indi-
     rally low in protein, but may include a food product                   vidual's station in life and physical and mental capac-
                                                                            ity.




                                                                  52
              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.
    Hospital Facility Services
    Inpatient Services                                                 Your Plan’s Hospital Benefits (Facility Services), Inpatient
                                                                       Services Copayment
    Outpatient Services                                                Your Plan’s Hospital Benefits (Facility Services), Outpatient
                                                                       Services, Services for illness or injury Copayment
    Partial Hospitalization2                                           Your Plan’s Ambulatory Surgery Center Benefits Copay-
                                                                       ment applies per Episode
    Professional (Physician) Services
    Inpatient Services                                                 Your Plan’s Professional (Physician) Benefits, Inpatient
                                                                       Physician Benefits Copayment
    Outpatient Service                                                 Your Plan’s Professional (Physician) Benefits, office visits
                                                                       Copayment
1      The Copayments above 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
      provides 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 described in your ASO Benefit                Inpatient Hospital and Professional Services; and
Booklet, your Plan provides coverage for Substance Abuse                 Outpatient Partial Hospitalization.
Condition Services as described in this Supplement. All
Services must be Medically Necessary. Residential care is           Prior to obtaining the Substance Abuse Condition Services
not covered. For a definition of Substance Abuse Condi-             listed above, you or your Physician must call the Claims
tion, see the Definitions section of your booklet.                  Administrator at 1-800-343-1691 to obtain prior authoriza-
                                                                    tion.
This Supplemental Benefit does not include Inpatient Ser-
vices which are Medically Necessary to treat the acute              Failure to obtain prior authorization or to follow the rec-
medical complications of detoxification, which are covered          ommendations of the Claims Administrator for Non-
as part of the medical Benefits of your health plan and not         Emergency Substance Abuse Condition Services as speci-
considered to be treatment of the Substance Abuse Condi-            fied above will result in the following:
tion itself.                                                             for Inpatient Hospital and Professional Services, an ad-
                                                                         ditional Member payment of $250 for each Hospital
It is your responsibility to ensure that the Provider you se-
                                                                         admission;
lect for Substance Abuse Condition Services is a Participat-
ing Provider. Participating Providers are indicated in the               for Outpatient Partial Hospitalization, non-payment of
Claims Administrator Provider Directory. For questions                   services by Blue Shield.
about these Substance Abuse Condition Benefits, or for
assistance in selecting a Participating Provider, Members           Benefits are provided for Medically Necessary Services for
should call customer service at the number listed in the back       Substance Abuse Conditions, as defined in your booklet,
of this booklet.                                                    and as specified in this Supplement. Residential care is not
                                                                    covered.
Prior authorization by the Claims Administrator is required
                                                                    This Benefit is subject to the general provisions, limitations
for Non-Emergency Substance Abuse Condition Services as
specified below.                                                    and exclusions listed in your booklet.




                                                                      53
                  Supplement B — Hearing Aid Services Benefit

Summary of Benefits

Benefit                                                         Member Copayment
Hearing aid Services as described in this Supplement                $700 combined per Member maximum allowance every 24
                                                                                          months

Introduction                                                        The hearing aid Benefit includes: a hearing aid instrument,
                                                                    monaural or binaural including ear mold(s), the initial bat-
In addition to the Benefits listed in your ASO Benefit Book-
                                                                    tery, cords and other ancillary equipment. The Benefit also
let, your Plan provides coverage for hearing aid Services,
                                                                    includes visits for fitting, counseling and adjustments.
subject to the conditions and limitations listed below.
                                                                    The following services and supplies are not covered:
The hearing aid Services Benefit provides a combined
maximum allowance every 24 months as shown on the                   1.   Purchase of batteries or other ancillary equipment, ex-
Summary of Benefits towards covered hearing aids and                     cept those covered under the terms of the initial hearing
Services as specified below. The hearing aid Services                    aid purchase;
Benefit is separate and apart from the other Benefits de-
                                                                    2.   Charges for a hearing aid which exceed specifications
scribed in your ASO Benefit Booklet. You are not required
                                                                         prescribed for correction of a hearing loss;
to use a Claims Administrator Preferred Provider to obtain
these services as the Claims Administrator does not main-           3.   Replacement parts for hearing aids, repair of hearing
tain a network of contracted providers for these services.               aids after the covered warranty period and replacement
You may obtain these services from any provider of your                  of hearing aids more than once in any period of 24-
choosing and submit a claim to the Claims Administrator                  month period;
for reimbursement for covered Services up to the combined
maximum allowance. For information on submitting a                  4.   Surgically implanted hearing devices.
claim, see the “Submitting a Claim Form” paragraphs in the          Hearing aids and ancillary equipment are included in the
Introduction section of your ASO Benefit Booklet.                   calculation of the Participant’s maximum Calendar Year
                                                                    Copayment responsibility.
Benefits
                                                                    This Benefit is subject to the general provisions, limitations
Hearing Aids and Ancillary Equipment                                and exclusions listed in your booklet.
The Benefit allowance is provided for hearing aids and an-
cillary 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.




                                                               54
NOTES




 55
                For claims submission and information contact the Claims Administrator.




                                              Blue Shield of California
                                                 P.O. Box 272540
                                               Chico, CA 95927-2540

                             Participants may call Customer Service Department toll free:

                                                  1-800-642-6155

                  The hearing impaired may call Customer Service through the toll-free TTY number:
                                                  1-800-241-1823


                            Benefits Management Program Telephone Numbers
                                      For Prior Authorization: 1-800-343-1691
            For prior authorization of Benefits Management Program Radiological Services: 1-888-642-2583
                             Please refer to the Benefits Management Program section of
                                              this booklet for information.




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