DDP: PPO, CDHP, and EPO DDNY: PPO and CDHP · DDP: PPO, CDHP, and EPO ... DDNY: PPO and CDHP HIGHLIGHTS Medical benefits 11 How to find a provider 12 Programs and services 13 Benefit

DDP: PPO, CDHP, and EPO(EPO for PA residents only)DDNY: PPO and CDHP

HIGHLIGHTS

Medical benefits 11

How to find a provider 12

Programs and services 13

Benefit summaries 16

2016 plans:

Effective January 1, 2016

Go with the plan that’s

right for you

When you go with the Preferred Provider Organization (PPO), Consumer-Directed Health Plan (CDHP), and Exclusive Provider Organization (EPO for PA residents only), and PPO and CDHP (DDNY), administered by Blue Shield of California, you’re on your way to quality health coverage, large provider networks, and a wide range of programs and services that help provide the most value from your coverage.

This booklet offers the information you need to choose the right health plan for you and your family.

Plan choices

During the 2016 annual enrollment period, Delta Dental is offering the following plans, administered by Blue Shield:

• DDP: PPO, CDHP, and EPO (EPO for PA residents only)

• DDNY: PPO and CDHP

To make it easier to compare the plans, we’ve included a description of the unique features of each and a benefit comparison chart on pages 10-11 of this booklet.

02 Blue Shield of California

PPOBy enrolling in the PPO, you can receive care from any of the physicians and hospitals within the plan’s network, as well as outside of the network for covered services.

Estimate your medical costs

Blue Shield’s Treatment Cost Estimator tool provides PPO plan members with estimates of both the total cost and out-of-pocket expenses for common in-network medical treatments and services. These estimates provide the transparency and clarity to help you budget and plan for future healthcare expenses. To access the tool, log in to blueshieldca.com, then click on Help & Support and then Treatment Cost Estimator.

If maintaining a relationship with your current doctor is important to you, then the PPO plan may be a good choice since the plan lets you continue seeing your current doctor for most covered services, even if

your doctor isn’t part of the plan’s provider network. Keep in mind that if your physician is not part of the plan’s PPO network, you will have to pay more for each visit.

Go to blueshieldca.com/deltadental 03

HOW THE PLAN WORKS When you see a network provider for covered services:

• PPO network providers will submit their claims to Blue Shield.

• You pay 100% of the allowed amount for services, except for preventive care, until you meet your calendar-year deductible.

• After you meet the calendar-year deductible amount, you pay a copayment or coinsurance for covered services.

When you see a non-network provider for covered services:

• You pay 100% of the amount billed for covered services until you’ve met your calendar-year deductible. Only the amount allowed by Blue Shield of California will apply to the deductible accumulation.

• After you meet the calendar-year deductible amount, you pay a copayment or coinsurance for covered services, which is based on Blue Shield’s allowable amount, plus any charges above the allowable amount. The additional charges above the allowable amount can be substantial.

• Non-network providers will usually require you to pay 100% of the cost of the service. You will then need to submit a claim along with the itemized bill from your provider to Blue Shield.

Plan highlights Here are a few highlights of the services covered by the PPO. For details on copayment and coinsurance amounts, please see the benefit overview on page 11. To find network providers, see page 12.

Preventive care – Provides access to services defined as routine preventive care at no additional charge and without having to pay a copayment or meet the plan’s deductible. You can download a list of recommended screenings and immunizations by going to blueshieldca.com/preventive.

Specialty care – You can access care through a specialist without a referral from your primary care physician.

Mental health and substance abuse care – You have access to inpatient and outpatient mental health and substance abuse care for issues such as depression, alcohol/drug abuse, mental illness, and marriage and family counseling through the Blue Shield PPO network and non-network providers. Keep in mind that if you see a provider that is not part of the plan’s PPO network, your out-of-pocket costs will be higher.

Urgent care – It’s possible to save time and money by going to an urgent care center instead of the emergency room. To find an urgent care center, visit blueshieldca.com/ucc-ppo.

Emergency care – You’re covered for emergency care around the world regardless of whether or not the provider is in your plan’s PPO network.

Chiropractic and acupuncture services – Visit any chiropractor or acupuncturist in the Blue Shield PPO network.

Pharmacy benefits – Offered through CVS Caremark. Note that prescription drug coverage benefits accrue to the combined plan out-of-pocket maximum.

Have questions? Get answers.

Call the Blue Shield Member Services team at (855) 256-9404.

Visit blueshieldca.com/deltadental to find providers, review medical benefits, and more.

Download the Blue Shield mobile app for iPhone or Android at blueshieldca.com/mobile.

Connect with Team Shield on Facebook/BlueShieldCA or Twitter/TeamShieldBSC and post a question.


Exclusive Provider Organization (EPO) planOnly available to Delta Dental Pennsylvania plan members living in Pennsylvania – the Blue Shield Exclusive Provider Organization (EPO) plan is structurally similar to an HMO plan, except that you do not need to select a Personal Physician.

Choosing a Personal Physician

This plan does not require you to choose a personal

physician; however, you must choose from physicians

and hospitals in the preferred provider network.

If you seek care as an EPO member, you choose from physicians and hospitals in the preferred provider (PPO) network in the state of Pennsylvania only. Non-network services and services outside of Pennsylvania are not covered, except for emergency care.


HOW THE PLAN WORKS For Pennsylvania residents only – with the Blue Shield EPO plan, there are no deductibles or coinsurance, and you only need to pay a copayment for most covered services like doctor visits, prescription drugs, urgent care visits, and emergency care (just to name a few). Other services have no copayment.

You only have access to providers in the Blue Shield PPO network. Services provided by non-network providers, except for emergencies, are not covered by the plan. For some services, Blue Shield may require that you use a specific network provider.

Plan highlights Here are a few highlights of the services covered by the EPO plan. For details on copayment amounts, please see the benefit overview on page 11. To find network providers, see page 12.


Specialty care – You can see any specialist in the PPO network when needed without prior authorization from your primary physician. However, some services may require prior authorization.

Mental health and substance abuse care – You have access to inpatient and outpatient mental health and substance abuse care for issues such as depression, alcohol/drug abuse, mental illness, and marriage and family counseling through the Blue Shield PPO network.

Urgent care – It’s possible to save time and money by going to an urgent care center instead of the emergency room. To find a network urgent care center, visit blueshieldca.com/ucc-ppo. If you receive care at an urgent care center that’s not in the Blue Shield PPO network, your plan may not cover the services you receive.









06 Blue Shield of California06 Blue Shield of California

CDHP with HSAThe CDHP is a high-deductible PPO plan that is paired with a health savings account (HSA),* a federal tax-free† savings account, administered by HealthEquity.‡

To start a health savings account with HealthEquity, you must enroll in the Health Savings Account (HSA) compatible CDHP. The CDHP allows you to receive care from any of the physicians and hospitals within the plan’s network, as well as outside of the network for covered services. The HSA helps you save money to help offset your deductible and other out- of-pocket medical expenses. See page 08 for the deductible amounts for this plan.

Plan highlights Here are a few highlights of the services covered by the CDHP. For details on copayment and coinsurance amounts, please see the benefit summaries starting on page 16. To find network providers, see page 12.

Low monthly premiums – The higher deductible and out-of-pocket maximum will lower your premium. That means you pay less each pay period and can choose to apply the savings to pay the deductible when you actually need care or to increase your HSA contributions.


Specialty care – You can access care through a specialist without a referral from your primary care physician.

Mental health and substance abuse care – You have access to inpatient and outpatient mental health and substance abuse care for issues such as depression, alcohol/drug abuse, mental illness, and marriage and family counseling through the Blue Shield PPO network and non-network providers. Keep in mind that if you see a provider that is not part of the plan’s PPO network, your

out-of-pocket costs will be higher.

Urgent care – It’s possible to save time and money by going to an urgent care center instead of the emergency room. To find an urgent care center, visit blueshieldca.com/ucc-ppo.




* Although most individuals who enroll in an HSA-compatible high-deductible health plan (HDHP) are eligible to open a health savings account (HSA), you should consult with a financial adviser to determine if the CDHP is a good financial fit for you. Blue Shield does not offer tax advice for HSAs, as HSAs are offered through financial institutions.

† Currently, for residents of California, Alabama, and New Jersey, HSA contributions are not excluded from state income tax. For more information, please consult your tax adviser

‡ The HSA is offered through HealthEquity, a company independent from Blue Shield of California. Blue Shield does not offer tax advice for HSAs since HSAs are offered through financial institutions. For more information about HSAs, eligibility, and the law’s current provisions, please consult your financial or tax adviser.


* Although most individuals who enroll in an HSA-compatible high-deductible health plan (HDHP) are eligible to open a health savings account (HSA), you should consult with a financial adviser to determine if the CDHP plan is a good financial fit for you. Blue Shield does not offer tax advice for HSAs, as HSAs are offered through financial institutions.

† Currently, for residents of California, Alabama, and New Jersey, HSA contributions are not excluded from state income tax. For more information, please consult your tax adviser.

‡ Based on a plan effective date of January 2016.

Health savings account (HSA) highlights

The HSA* works very much like a savings account. You can contribute pre-tax dollars and let it grow from year to year. The funds are federal tax-free† and can be used to pay for your deductible and qualified out-of-pocket medical expenses. You can also save it and let it grow from year to year. This can be a good way to save money for long-term care costs or in retirement.

Below are a few highlights of the HSA. For more information on the HSA, go to healthequity.com/deltadental.

• If you change jobs, retire, or leave the health plan, you take the money with you wherever you go – it’s yours to keep.

• Once your HSA balance accrues more than $2,000, you can invest any amount in excess of the $2,000 into a mutual fund.

• Even though you do not need your receipts to get reimbursement from the HSA, keep your receipts in case of an IRS audit.

• All contributions, earnings, and withdrawals for eligible healthcare expenses are federal tax-free.

To view an up-to-date list of HSA qualified medical expenses, download or order IRS Publication 502 by calling the IRS at 1-800-TAX-FORM (1-800-829-3676) or by visiting www.irs.gov.

Plan coverage effective January 2016

DELTA DENTAL CONTRIBUTION*

YOUR CONTRIBUTION LIMIT‡

(IRS LIMIT – DELTA DENTAL CONTRIBUTION)

IRS ANNUALLIMITS

< age 55

Single Coverage $500 $2,850 $3,350

Family Coverage $1,000 $5,750 $6,750

Age 55+

Single Coverage $500 $3,850 $4,350

Family Coverage $1,000 $6,750 $7,750

Important notes about the chart above:

• You and Delta Dental contributions are based on an CDHP coverage effective date of July.

• If your coverage is effective after July, Delta Dental contribution will be prorated for the calendar year and you should adjust your own contributions to comply with IRS limits.

• Family coverage includes Employee + Spouse/Domestic Partner/Adult Dependent.

Contributing to your HSAMember contributions and limits

08 Blue Shield of California08 Blue Shield of California

How the CDHP and HSAwork togetherYou can use your HSA* to pay for your plan’s deductible and/or out-of-pocket maximum. Or you can leave the funds invested in the account for future medical expenses and save for long-term care costs federal tax-free.† Here’s how it works.

* Although most individuals who enroll in an HSA-compatible high-deductible health plan (HDHP) are eligible to open a health savings account (HSA), you should consult with a financial adviser to determine if the CDHP is a good financial fit for you. Blue Shield does not offer tax advice for HSAs, as HSAs are offered through financial institutions.

† Currently, for residents of California, Alabama, and New Jersey, HSA contributions are not excluded from state income tax. For more information, please consult your tax adviser.

Using the HSA to pay for medical or pharmacy benefits

Medical services

Visit a provider and receive services.

Your provider bills Blue Shield.

Blue Shield sends you an EOB.

Your provider sends you an invoice.

Pay your invoice with your HSA:• Use your HSA debit card; or• Pay provider directly through

healthequity.com; or• Use another method of payment

and reimburse yourself through healthequity.com

Pharmacy services

Fill or refill a prescription

The pharmacy verifies your pharmacy coverage and provides a cost for your prescription(s).

Pay for prescription using your HSA:• Use your HSA debit card; or• Use another method of payment

and reimburse yourself through healthequity.com

Using your HSA to cover your deductible

If your CDHP Plan coverage effective date is January, below are the amounts that you would need to contribute to your HSA to cover your calendar-year-deductible.

NETWORK DEDUCTIBLEDELTA DENTAL

CONTRIBUTION TO HSAADDITIONAL HSA CONTRIBUTIONS

NEEDED TO COVER DEDUCTIBLE

Single coverage $1,500 $500 $1,000

Family coverage $3,000 $1,000 $2,000


* Contributions are pre-tax estimates and do not include accrued HSA interest. Currently, for residents of California, Alabama, and New Jersey, HSA contributions and earnings are not excluded from state income tax. For more information, please consult your tax adviser.

DESIRED HSA BALANCE IN 12 MONTHS

CLIENT CONTRIBUTION

EXAMPLE MEMBER CONTRIBUTION (TIMING SUBJECT TO PAYROLL CYCLE)

YEARLY MONTHLY BIWEEKLY WEEKLY

Single coverage

$1,500 $500 $1,000 $83 $42 $19

$2,000 $500 $1,500 $125 $63 $29

Family coverage

$3,000 $1,000 $2,000 $167 $83 $38

$3,500 $1,000 $2,500 $208 $104 $48

Examples of weekly and monthly contribution amounts

The monthly and weekly contributions below are based on contributions over a 12-month or 52-week period.

Growing your HSA balance with weekly or monthly contributions

By contributing as little as $19 per week pre-tax to an HSA –approximately the cost of four barista coffees – members with single coverage can save enough to cover their deductible. Members with family coverage can save enough to meet their network deductible by contributing about $38 per week to their HSA.

Estimating your medical/pharmacy expendituresCDHP members – Blue Shield’s Treatment Cost Estimator tool provides Health Savings Plan members with estimates of both the total cost and out-of-pocket expenses for common network medical treatments and services. These estimates provide the transparency and clarity to help you manage and plan for future healthcare expenses. To access this tool, go to blueshieldca.com/deltadental and select Log in to blueshieldca.com. If you don’t have an online account, select Register for an online account. Once logged in, click on Help & Support and then Treatment Cost Estimator.

Non-members – If you are not currently enrolled in the Health Savings Plan, then you can estimate your medical costs through fairhealthconsumer.org, a third-party website that is not affiliated with Blue Shield.

Important: fairhealthconsumer.org does indicate whether providers are part of the Blue Shield network, and the estimated costs do not reflect Blue Shield negotiated network discounts. Actual costs for services may vary depending on the plan you enroll in and the providers you access for services. FAIR Health’s agreements with third parties place limits on the number of medical and dental searches that can be done on the site. Consumers can conduct 15 searches of up to five medical codes per week and 10 searches of up to five dental codes per week. Learn more at fairhealthconsumer.org/faq.


Compare plan features

PPO & CDHP EPO plan (for PA residents only)

NETWORK NON-NETWORK NETWORK NON-NETWORK

Out-of-pocket costs

Pay a copayment or coinsurance for covered services. (Calendar-year deductible may apply.)

After calendar-year deductible is met, pay a percentage of costs and all costs above the allowable amount.

Pay a copayment covered services.

Non-network services are not covered, except for urgent and emergency care.

Choosing a doctor

Visit any PPO network physician.

Visit any PPO network specialist; no referral is required.

Visit any non-network physician, pay for the services, and submit claims to Blue Shield.

Visit any non-network specialist and submit claims to Blue Shield.

No referral is required.

Visit any PPO network physician in Pennsylvania only.

Visit any PPO network specialist in Pennsylvania only; no referral is required.

Non-network services are not covered, except for emergency care.

Access to specialists

Visit any PPO network specialist; no referral required.

Visit any non-network specialist and submit claims to Blue Shield.

No referral is required.

Visit any PPO network specialist; no referral required.

Non-network services are not covered, except for urgent and emergency care.

* To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by an MHSA network participating provider.


Compare plan benefits

PPO CDHP EPO plan (for PA residents only)

NETWORK NON-NETWORK NETWORK NON-NETWORK NETWORK

Plan -year deductible (applies to out-of-pocket maximum)

$500 per individual/ $1,000 per family

$1,000 per individual/ $2,000 per family

$1,500 per individual/ $3,000 per family*

$3,000 per individual/ $6,000 per family*

None

Plan-year out-of-pocket maximum or copayment maximum



$3,000 per individual/ $6,000 per familyt



MEMBER COPAYMENT/COINSURANCE MEMBER COPAYMENT/COINSURANCE MEMBER COPAYMENT

Physician office visit 20% 40% 10% 30% $20 per visit

Specialist office visit 20% 40% 10% 30% $40 per visit

Preventive health benefits

No charge (not subject to the

calendar-year deductible)

40%

No charge (not subject to the


30% No charge

Outpatient X-ray, pathology, and laboratory

20% 40% 10% 30% No charge

Outpatient surgery in hospital 20% 40% 10% 30% $100 per visit

Inpatient facility services (non-emergency)

20% 40% 10% 30% $250 per admission

Emergency room services (not resulting in admission)

20% (not subject to the


20% (not subject to the


10% 30% $150 per visit

Mental health services (outpatient services)

20% 40% 10% 30% $20 per visit

Substance abuse (inpatient/outpatient physician visit)

20% 40% 10% 30%

Inpatient: No chargeOutpatient: $20 per visit

Pregnancy and maternity care benefits‡ 20% 40% 10% 30% No charge

Acupuncture benefits20%

(up to 20 visits per plan-year)

40% (up to 20 visits per plan-year)



Not covered

Chiropractic benefits (provided by a chiropractor)

20% (up to 12 visits

per plan-year)


per plan-year)


per plan-year)


per plan-year)

$20 (up to 12 visits

per plan-year)

* For family coverage, the full family deductible must be met before enrollee or covered dependents can receive benefits.

† For family coverage, the full family out-of-pocket must be met before enrollee or covered dependents can receive 100% coverage.

‡ Prenatal and postnatal physician office visits. For inpatient hospital services, see “Hospitalization Services” on the benefit summary in the back of this booklet.


Search for a network provider

Within the United States

• Go to provider.bcbs.com.

• Enter the first three letters of your member ID or DDR or select the BlueCard PPO/EPO network.

• Search by Keyword or by Specialty.

• Enter a location and a radius to search by (default is 5 miles).

• Click on Go.

Outside of the United States

• Go to bluecardworldwide.com.

• Accept the terms and conditions.

• Enter the first three letters of your member ID or DDR.

• Click Login.

Find a network providerBlue Shield’s networks are some of the largest nationwide.The PPO network includes more than 70,000 physicians and 350 hospitals.

If you don’t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team at (855) 256-9404 for personal assistance or to request a provider directory.


Going with Blue Shield means added programs and services

Condition management programsThese programs offer nurse support as well as education and self-management tools for members with asthma, diabetes, coronary artery disease, heart failure, and chronic obstructive pulmonary disease.

NurseHelp 24/7Speak with registered nurses anytime, day or night, and get answers to your health-related questions, or go online to have a one-on-one personal chat with a registered nurse anytime. The NurseHelp 24/7SM phone number is conveniently located on the back of your member ID card.

Prenatal Education Prenatal Education promotes a healthy pregnancy with helpful information about prenatal and postpartum care. Members receive an educational packet as well as a book of their choice that provide practical recommendations for maintaining a healthy lifestyle before, during, and after pregnancy, and caring for infants through the toddler years.

Wellness discount programsBlue Shield offers a variety of member discounts on popular weight loss, fitness, vision, and health and wellness programs1 that can help you save money and get healthier.

• Weight Watchers – Get discounts on three- and 12-month subscriptions, and monthly passes.

• 24 Hour Fitness – Enjoy waived enrollment, processing, and initiation fees and discounts on monthly membership dues.

• Alternative Care Discount Program – Get 25% off usual and customary fees for acupuncture, chiropractic services, and massage therapy, plus get discounts on health and wellness products, with free shipping on most items.

• Discount Provider Network2 – Take 20% off the published retail prices when you use a participating provider in the Discount Vision Program network for exams, frames, lenses, and more.

• MESVision Optics – Take advantage of competitive prices on contact lenses,3 sunglasses, readers, and eyecare accessories, with free shipping on orders over $50. Blue Shield vision plan members can apply their benefits to reduce their out-of-pocket costs for contact lenses.

Please refer to the endnotes on inside back cover for all pertinent wellness discount program notations.







About the ClinicsMinuteClinic walk-in healthcare centers are staffed by board-certified nurse practitioners focused on preventive care, vaccinations, and treatment for minor illnesses and injuries.†

The clinics are:

• Quick – Visits take about 15 minutes,‡ and you never need an appointment.

• Affordable – Copayments are the same as a visit to your primary care physician.

• Convenient – They’re located in select CVS locations and are open every day.

Find a MinuteClinic Visit MinuteClinic next time you need affordable, non-emergency medical care. To find a contracted MinuteClinic, just go to blueshieldca.com/findaprovider. Choose “Facilities” and click on Advanced Search. Under “Facility type,” choose Retail Health Clinics. Edit the “Located near” field, or keep the defaults. Click Find now to see results.

MinuteClinic national locator on CVS website: cvs.com/minuteclinic/clinic-locator.

Quick, convenient health care for busy peopleAvailable for Blue Shield PPO members!*

Whether you want your cholesterol checked, you hurt your ankle, or you have a child with a sore throat, MinuteClinic can help. They offer affordable, non-emergency health care seven days a week – and you don’t need an appointment.

* Members must access locations currently contracted with their Blue Shield PPO network in order to receive network rates.

† For a full list of services available, go to minuteclinic.com.

‡ Visit times may vary based on services provided.


Review benefit summaries

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Delta Dental of Pennsylvania ASO PPO 500 80-60 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California

Effective: January 1, 2016 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Participating Providers1 Non-Participating

Providers2 Calendar Year Medical Deductible (Participating and Non-Participating deductibles accrue separately)

$500 per individual / $1,000 per family

$1,000 per individual / $2,000 per family

Calendar Year Out-of-Pocket Maximum (Includes the calendar year medical deductible. Copayments or coinsurance for covered services from Participating Providers accrue to both the Participating and Non-Participating Provider Calendar-Year out-of-pocket maximum amounts)



Lifetime Benefit Maximum None

Covered Services Member Copayment OUTPATIENT PROFESSIONAL SERVICES Participating Providers1 Non-Participating

Providers2 Professional (Physician) Benefits

Physician and specialist office visits 20% 40% Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services

20% 40%

Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

20% 40%

Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections (separate office visit copayment may apply)

20% 40%

Preventive Health Benefits11 Preventive health services (as required by applicable Federal law) No Charge

(not subject to the calendar year medical deductible)

40%

OUTPATIENT FACILITY SERVICES Outpatient surgery performed at a free-standing ambulatory surgery center

20% 40%3

Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center

20% 40%3

Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")

20% 40%3

Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services

20% 40%3


20% 40%3

Bariatric surgery (prior authorization is required; medically necessary surgery for weight loss, for morbid obesity only)4

20% 40%3

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services)

Inpatient physician services 20% 40% Inpatient non-emergency facility services (semi-private room and board, and medically necessary services and supplies, including subacute care)

20% 40%5


20% 40%5


Inpatient Skilled Nursing Benefits6 Covers up to 100 days per calendar year combined with Hospital Skilled Nursing Facility Unit.

Free-standing skilled nursing facility 20% 20%7 Skilled nursing unit of a hospital 20% 40%5

EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not apply if the member is directly admitted to the hospital for inpatient services)

20% (not subject to the calendar year

medical deductible)

20% (not subject to the calendar year medical

deductible) Emergency room services resulting in admission (when the member is admitted directly from the ER)

20% 20%

Emergency room physician services 20% 20% AMBULANCE SERVICES

Emergency or authorized transport (ground or air) 20% 20% PROSTHETICS/ORTHOTICS

Prosthetic equipment and devices (separate office visit copayment may apply)

20% 40%

Orthotic equipment and devices (separate office visit copayment may apply) 20% 40% DURABLE MEDICAL EQUIPMENT

Breast pump No Charge (not subject to the calendar year

medical deductible)

Not Covered

Other durable medical equipment 20% 40% MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES8,9

Inpatient hospital services 20% 40%5 Residential care 20% 40%5 Inpatient physician services 20% 40% Routine outpatient mental health and substance abuse services (includes professional/physician visits)

20% 40%

Non-routine outpatient mental health and substance abuse services (includes electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization programs, psychological testing and transcranial magnetic stimulation)

20% 40%

HOME HEALTH SERVICES Home health care agency services (up to 100 visits per calendar year)6 20% Not Covered10

Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency

20% Not Covered10

HOSPICE PROGRAM BENEFITS

Routine home care 20% Not Covered10 Inpatient respite care 20% Not Covered10 24-hour continuous home care 20% Not Covered10 Short-term inpatient care for pain and symptom management 20% Not Covered10

CHIROPRACTIC BENEFITS6 Chiropractic spinal manipulation (up to 12 visits per calendar year) 20% 40%

ACUPUNCTURE BENEFITS6 Acupuncture services (up to 20 visits per calendar year) 20% 40%

REHABILITATION AND HABILITATION BENEFITS (Physical, Occupational and Respiratory Therapy) Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility)

20% 40%

SPEECH THERAPY BENEFITS Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility)

20% 40%

PREGNANCY AND MATERNITY CARE BENEFITS Prenatal and postnatal physician office visits (when billed as part of global maternity fee including hospital inpatient delivery services)

20% 40%

Abortion services (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

20% 40%


ASO (1/16) SD 092215

FAMILY PLANNING BENEFITS Counseling and consulting (includes insertion of IUD, as well as injectable and implantable contraceptives for women)

No Charge (not subject to the calendar year

medical deductible)

40%

Tubal ligation (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility)

No Charge (not subject to the calendar year

medical deductible)

40%

Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

20% 40%

DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies 20% 40% Diabetes self-management training 20% 40%

CARE OUTSIDE OF PLAN SERVICE AREA Benefits provided through the BlueCard® Program are paid at the participating level. Member’s cost share will be either a copayment or coinsurance based on the lower of billed charges or the negotiated allowable amount for participating providers as agreed upon with the local Blue’s Plan.

Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit

1 Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. After the calendar year medical deductible is met, the member is responsible for copayments/coinsurance for covered services from participating providers. Participating providers agree to accept Blue Shield's allowable amount plus any applicable member copayment or coinsurance as full payment for covered services.

2 Non-participating providers can charge more than Blue Shield’s allowable amounts. When members use non-participating providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum.

3 The maximum allowed charges for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-participating hospital is $350 per day. Members are responsible for 40% of this $350 per day, and all charges in excess of $350 per day. Amounts that exceed the benefit maximums do not count toward the calendar year out-of-pocket maximum and continue to be the member’s financial responsibility after the calendar year maximums are reached.

4 Bariatric surgery is covered when prior authorized by Blue Shield. Refer to the Plan Contract for further details. 5 The maximum allowed charges for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 40% of

this $600 per day, and all charges in excess of $600 per day. Amounts that exceed the benefit maximum do not count toward the calendar year out-of-pocket maximum and continue to be the member’s responsibility after the calendar year maximums are reached.

6 For plans with a calendar year medical deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met.

7 Services may require prior authorization. When services are prior authorized, members pay the participating provider amount. 8 Mental Health and Substance Abuse services are accessed through Blue Shield’s participating and non-participating providers. 9 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Plan Contract for benefit

details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 10 Services from non-participating providers for home health care and hospice services are not covered unless prior authorized. When these services are prior authorized,

the member’s copayment or coinsurance will be calculated at the participating provider level, based upon the agreed upon rate between Blue Shield and the agency. 11 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered

non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance

Plan designs may be modified to ensure compliance with Federal requirements.


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Delta Dental of Pennsylvania ASO EPO Plan Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California

Effective: January 1, 2016 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Participating Providers1 Calendar Year Medical Deductible None Calendar Year Out-of-Pocket Maximum $2,000 per individual / $4,000 per family Lifetime Benefit Maximum None

Covered Services Member Copayment OUTPATIENT PROFESSIONAL SERVICES Participating Providers1 Professional (Physician) Benefits

Physician office visits (Includes OB/GYN, Pediatrician, Internal Medicine, Family Practice and General Practice)2

$20 per visit

Specialist office visits (Includes all other provider designations)2 $40 per visit Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services

No Charge


No Charge


No Charge



$100 per visit

Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center

$100 per visit

Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")

No Charge


No Charge


No Charge

Bariatric surgery Not Covered HOSPITALIZATION SERVICES Hospital Benefits (Facility Services)

Inpatient physician services No Charge Inpatient non-emergency facility services (semi-private room and board, and medically necessary services and supplies, including subacute care)

$250 per admission

Bariatric surgery Not Covered Inpatient Skilled Nursing Benefits3,4 Combined maximum of up to 60 days per calendar year.

Free-standing skilled nursing facility $50 per day Skilled nursing unit of a hospital $50 per day



$150 per visit

Emergency room services resulting in admission (when the member is admitted directly from the ER)

$250 per admission

Emergency room physician services No Charge AMBULANCE SERVICES

Emergency or authorized transport (ground or air) $100 per trip PROSTHETICS/ORTHOTICS

Prosthetic equipment and devices (separate office visit copayment may apply)

No Charge

Orthotic equipment and devices (separate office visit copayment may apply) No Charge DURABLE MEDICAL EQUIPMENT

Breast pump No Charge Other durable medical equipment No Charge

MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES5,6 Inpatient hospital services $250 per admission Residential care $250 per admission Inpatient physician services No Charge Routine outpatient mental health and substance abuse services (includes professional/physician visits)

$20 per visit

Non-routine outpatient mental health and substance abuse services (includes electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization program, psychological testing and transcranial magnetic stimulation)

No Charge

HOME HEALTH SERVICES Home health care agency services (up to 100 visits per calendar year)3 $20 per visit

Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency

$20 per visit

HOSPICE PROGRAM BENEFITS

Routine home care No Charge Inpatient respite care No Charge 24-hour continuous home care $75 per day Short-term inpatient care for pain and symptom management $75 per day

CHIROPRACTIC BENEFITS3 Chiropractic spinal manipulation (up to 12 visits per calendar year) $20 per visit

ACUPUNCTURE BENEFITS Acupuncture services Not Covered

REHABILITATION AND HABILITATION BENEFITS (Physical, Occupational and Respiratory Therapy) Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility)

$20 per visit


$20 per visit


No Charge


$100 per surgery


No Charge

Tubal ligation (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility)

No Charge


$75 per surgery

DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies (for testing supplies see Outpatient Prescription Drug Benefits)

No Charge

Diabetes self-management training $20 per visit


ASO (1/16) SD 092115


Within US: BlueCard Program See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit

1 Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. After the calendar year medical deductible is met, the member is responsible for copayments/coinsurance for covered services from participating providers. Participating providers agree to accept Blue Shield's allowable amount plus any applicable member copayment or coinsurance as full payment for covered services.

2 When services are provided by a Participating Specialist, a $40 copayment per visit applies. 3 For plans with a calendar year medical deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether

the calendar year medical deductible has been met. 4 Services may require prior authorization. When services are prior authorized, members pay the participating provider amount. 5 Mental Health and Substance Abuse services are accessed through Blue Shield’s participating and non-participating providers. 6 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Plan Contract for benefit

details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 7 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered

non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance



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Delta Dental of Pennsylvania ASO CDHP Aggregate Deductible 1500/3000 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California Effective: January 1, 2016 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Participating Providers1

Non-Participating Providers2

Calendar Year Medical Deductible (Participating and Non-Participating deductibles accrue separately.) For family coverage, the full family deductible must be met before the enrollee or covered dependents can receive benefits for covered services.



Calendar Year Out-of-Pocket Maximum (Includes the calendar year medical deductible.) For family coverage, the full family out-of-pocket maximum must be met before the enrollee or covered dependents can receive 100% benefits for covered services.



Lifetime Benefit Maximum None Covered Services Member Copayment OUTPATIENT PROFESSIONAL SERVICES Participating

Providers1 Non-Participating

Providers2 Professional (Physician) Benefits

Physician and specialist office visits 10% 30% Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services

10% 30%


10% 30%


10% 30%


(not subject to the calendar year medical deductible)

30%


10% 30%3

Outpatient surgery performed in a hospital or hospital affiliated ambulatory surgery center

10% 30%3

Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits" and “Speech Therapy Benefits”)

10% 30%3


10% 30%3


10% 30%3


10% 30%3

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services)

Inpatient physician services 10% 30% Inpatient non-emergency facility services (semi-private room and board, and medically necessary services and supplies, including subacute care)

10% 30%5


10% 30%5

Inpatient Skilled Nursing Benefits6 (combined maximum of up to 100 days per benefit period; semi-private accommodations)

Free-standing skilled nursing facility 10% 10%7 Skilled nursing unit of a hospital 10% 30%5



10% 10%

Emergency room services resulting in admission (when the member is admitted directly from the ER)

10% 10%

Emergency room physician services 10% 10% AMBULANCE SERVICES

Emergency or authorized transport (ground or air) 10% 10% PROSTHETICS/ORTHOTICS

Prosthetic equipment and devices (separate office visit copayment may apply) 10% 30% Orthotic equipment and devices (separate office visit copayment may apply) 10% 30%

DURABLE MEDICAL EQUIPMENT Breast pump No Charge

(not subject to the calendar year medical

deductible)

Not Covered

Other durable medical equipment 10% 30% MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES8,9

Inpatient hospital services 10% 30%5 Residential care 10% 30%5 Inpatient physician services 10% 30% Routine outpatient mental health and substance abuse services (includes professional/physician visits)

10% 30%

Non-routine outpatient mental health and substance abuse services (includes electroconvulsive therapy, intensive outpatient programs, office-based opioid treatment, partial hospitalization program, psychological testing and transcranial magnetic stimulation)

10% 30%

HOME HEALTH SERVICES Participating Providers1

Non-Participating Providers2

Home health care agency services (up to 100 visits per calendar year)6 10% Not Covered10 Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency

10% Not Covered10

HOSPICE PROGRAM BENEFITS10

Routine home care 10% Not Covered10 Inpatient respite care 10% Not Covered10 24-hour continuous home care 10% Not Covered10 Short-term inpatient care for pain and symptom management 10% Not Covered10

CHIROPRACTIC BENEFITS6 Chiropractic spinal manipulation (up to 12 visits per calendar year) 10% 30%

ACUPUNCTURE BENEFITS6 Acupuncture services (up to 20 visits per calendar year) 10% 30%

REHABILITATION and HABILITATION BENEFITS (Physical, Occupational and Respiratory Therapy) Office location (an additional facility copayment may apply when services are rendered in a hospital or skilled nursing facility)

10% 30%


10% 30%


10% 30%


10% 30%


No Charge (not subject to the calendar

year medical deductible)

30%

Tubal ligation (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

No Charge (not subject to the calendar

year medical deductible)

30%


10% 30%


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ASO (1/16) SD 100215

DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies 10% 30% Diabetes self-management training 10% 30%


Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit

1 Unless otherwise specified, copayments/coinsurance are calculated based on allowable amounts. After the calendar year medical deductible is met, the member is responsible for a copayment/coinsurance for covered services from participating providers. Participating providers agree to accept Blue Shield's allowable amount plus any applicable member copayment or coinsurance as full payment for covered services.

2 Non-participating providers can charge more than Blue Shield’s allowable amounts. When members use non-participating providers, they must pay the applicable deductibles, copayments or coinsurance plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the calendar year medical deductible or out-of-pocket maximum.

3 The maximum allowed charges for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-participating hospital is $350 per day. Members are responsible for 30% of this $350 per day, and all charges in excess of $350 per day. Amounts that exceed the benefit maximums do not count toward the calendar year out-of-pocket maximum and continue to be the member’s financial responsibility after the calendar year maximums are reached.

4 Bariatric surgery is covered when prior authorized by Blue Shield. Refer to the Plan Contract for further details. 5 The maximum allowed charges for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 30%

of this $600 per day, and all charges in excess of $600 per day. Amounts that exceed the benefit maximum do not count toward the calendar year out-of-pocket maximum and continue to be the member’s responsibility after the calendar year maximums are reached.

6 For plans with a calendar year medical deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met.

7 Services may require prior authorization. When services are prior authorized, members pay the participating provider amount. 8 Mental Health and Substance Abuse services are accessed through Blue Shield’s Participating and Non-Participating providers. 9 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Plan Contract for

benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers.

10 Services from non-participating providers for home health care and hospice services are not covered unless prior authorized. When these services are prior authorized, the member‘s copayment or coinsurance will be calculated at the participating provider level, based upon the agreed upon rate between Blue Shield and the agency.

11 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance.



Calendar year: A period beginning at 12:01 a.m. on January 1 and ending at 12:01 a.m. of the next year.

Claim: A notification to your health plan that a service has been provided and payment is requested.

Coinsurance: A percentage of the cost for covered services that a member pays under the health plan after the deductible has been met.

Copayment: The dollar amount that a member is required to pay for certain benefits. Also called a “copay.”

Emergency services: Services for an unexpected medical condition, including a psychiatric emergency medical condition, manifesting itself by acute symptoms of sufficient severity (including severe pain) such that a layperson who possesses an average knowledge of health and medicine could reasonably assume that the absence of immediate medical attention could be expected to result in any of the following: placing the member’s health in serious jeopardy; serious impairment to bodily functions; or serious dysfunction of any bodily organ or part.

Inpatient: An individual who has been admitted to a hospital as a registered bed patient, and is receiving services under the direction of a physician.

Outpatient: An individual receiving services but not as an inpatient.

Out-of-pocket maximum: Your maximum copayment responsibility each calendar year for covered services. However, copayments for a very small number of covered services do not apply to the annual out-of-pocket maximum, and you continue to be responsible for copayments for those services when the out-of-pocket maximum is reached.

Personal Physician (also known as a primary care physician): A general practitioner, family practitioner, internist, obstetrician/gynecologist, or pediatrician who has contracted with the plan as a Personal Physician to provide primary care to members and to refer, authorize, supervise, and coordinate the provision of all benefits to members in accordance with the agreement.

Preventive care: Medical services provided by a physician for the early detection of disease when no symptoms are present and for routine physical examinations, usually limited to one visit per calendar year for members age 18 and over.

Services: Includes medically necessary healthcare services and medically necessary supplies furnished incident to those services.

Not sure what it means?

Use this glossary as a handy reference to some common health benefit terms.

Glossary


1 These discount program services are not a covered benefit of PPO, CDHP or EPO plans, and none of the terms or conditions of the PPO, CDHP or EPO plans apply.

The networks of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy, nor does Blue Shield make any recommendations, presentations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products.

Some services offered through the discount program may already be included as part of the Blue Shield plan covered benefits. Members should access those covered services prior to using the discount program.

Participants who are not satisfied with products or services received from the discount program may use Blue Shield’s grievance process described in the Benefit Booklet. Blue Shield reserves the right to terminate this program at any time without notice.

Discount programs administered by or arranged through the following independent companies:

• Alternative Care Discount Program – American Specialty Health Systems, Inc. and American Specialty Health Networks, Inc.

• Discount Provider Network and MESVisionOptics.com – MESVision

• Weight control – Weight Watchers North America

• Fitness facilities – 24 Hour Fitness, ClubSport, and Renaissance ClubSport

• LASIK – QualSight, Inc. and NVISION Laser Eye Centers

Note: No genetic information, including family medical history, is gathered, shared, or used from these programs.

2 The Discount Provider Network is available throughout California. Coverage in other states may be limited. Find participating providers by going to blueshieldca.com/fap.

3 Requires a prescription from your doctor or licensed optical professional.

Notice on the availability of language assistance services to accompany vital documents issued in English IMPORTANT: Can you read this letter? If not, we can have somebody help you read it.

You may also be able to get this letter written in your language. For free help, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) 346-7198.

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Blue Shield o al (866) 346-7198.

(Spanish)

重要通知：您能讀懂這封信嗎？如果不能，我們可以請人幫您閱讀。

這封信也可以用您所講的語言書寫。如需幫助，請立即撥打登列在您的Blue

Shield ID卡背面上的會員/客戶服務部的電話，或者撥打電話866-346-7198。 (Chinese)

QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue Shield của quý vị hoặc theo số 866-346-7198. (Vietnamese)

Language Assistance

Notice on the availability of language assistance services to accompany vital documents issued in English.

Wellness discount program endnotes

Member confidentiality

Blue Shield protects the confidentiality and privacy of your personal and health information, including medical information and individually identifiable information such as your name, address, telephone number, and Social Security number. To ensure this, Blue Shield requires a signed authorization form for you to access health information for your spouse or dependents over the age of 18.

To request an authorization form, log in to blueshieldca.com and select My Health Plan. Click on Download Forms under “Tools” on the right side. Scroll down to “Release of information” and click on Personal and Health Information Release. If you don’t have access to the Internet, or have questions about how Blue Shield protects your privacy and confidentiality, please call our Privacy Office directly at (888) 266-8080.

App Store is a service mark of Apple Inc.

iPhone is a trademark of Apple Inc., registered in the U.S. and other countries.

Blue Shield and the Shield symbol are registered trademarks of the BlueCross BlueShield Association, an association of independent Blue Cross and Blue Shield plans.

hgo with

Go with Blue Shield for a healthier you.

For more information, visit blueshieldca.com/deltadental, download the Blue Shield of California mobile app through the App StoreSM or Google Play, or call your dedicated Blue Shield Member Services team at (855) 256-9404 from 7 a.m. to 7 p.m., Monday through Friday.

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DDP: PPO, CDHP, and EPO DDNY: PPO and CDHP · DDP: PPO, CDHP, and EPO ... DDNY: PPO and CDHP HIGHLIGHTS Medical benefits 11 How to find a provider 12 Programs and services 13 Benefit