HCL America Inc Gold

8/10/2019 HCL America Inc Gold

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Claims Administered by Blue Shield of California

Gold Plan

Benefit Booklet

HCL America Inc.

Group Number: 970363 & 970364

Effective Date: J anuary 1, 2014

A n i n d e p e n d e n t m e m

b e r o f t h e B l u e S h i e l d A s s o c i a t i o n


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PLEASE NOTE

Some hospitals and other providers do not provide one or more of the following services that maybe covered under your Plan and that you or your family member might need: family planning;contraceptive services, including emergency contraception; sterilization, including tubal ligationat 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 practiceassociation, or clinic, or call the health Plan at the 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 (1/13)


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The Comprehensive Preferred Medical Plan

Participant Bill of Rights

As a Comprehensive Preferred Medical Plan Participant, you have the right to:

1. Receive considerate and courteous care, with respect

for your right to personal privacy and dignity.

2. Receive information about all health Services availa-ble to you, including a clear explanation of how toobtain them.

3. Receive information about your rights and responsi-bilities.

4. Receive information about your Preferred MedicalPlan, the Services we offer you, the Physicians andother practitioners available to care for you.

5. Have reasonable access to appropriate medical ser-vices.

6. Participate actively with your Physician in decisionsregarding your medical care. To the extent permittedby law, you also have the right to refuse treatment.

7. A candid discussion of appropriate or MedicallyNecessary treatment options for your condition, re-gardless of cost or benefit coverage.

8. Receive from your Physician an understanding ofyour medical condition and any proposed appropriateor Medically Necessary treatment alternatives, includ-ing available success/outcomes information, regardlessof cost or benefit coverage, so you can make an in-formed decision before you receive treatment.

9. Receive preventive health Services.

10. Know and understand your medical condition, treat-ment plan, expected outcome, and the effects thesehave on your daily living.

11. Have confidential health records, except when disclo-sure is required by law or permitted in writing byyou. With adequate notice, you have the right to re-view your medical record with your Physician.

12. Communicate with and receive information fromCustomer Service in a language you can understand.

13. Know about any transfer to another Hospital, includ-ing information as to why the transfer is necessary

and any alternatives available.14. Be fully informed about the Claims Administrator

dispute procedure and understand how to use it with-out fear of interruption of health care.

15. Voice complaints or grievances about the PreferredMedical Plan or the care provided to you.

16. Make recommendations regarding the Claims Ad-ministrators Member rights responsibilities policy.


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The Comprehensive Preferred Medical Plan

Participant Responsibilities

As a Comprehensive Preferred Medical Plan Participant, you have the responsibility to:

1. Carefully read all Claims Administrator Preferred

Medical Plan materials immediately after you are en-rolled so you understand how to use your Benefitsand how to minimize your out of pocket costs. Askquestions when necessary. You have the responsibil-ity to follow the provisions of your Claims Adminis-trator Preferred Medical Plan as explained in thisbooklet.

2. Maintain your good health and prevent illness bymaking positive health choices and seeking appropri-ate care when it is needed.

3. Provide, to the extent possible, information that yourPhysician, and/or the Plan need to provide appropri-

ate care for you.4. Understand your health problems and take an active

role in developing treatment goals with your medicalprovider, whenever possible.

5. Follow the treatment plans and instructions you andyour Physician have agreed to and consider the po-tential consequences if you refuse to comply withtreatment plans or recommendations.

6. Ask questions about your medical condition andmake certain that you understand the explanationsand instructions you are given.

7. Make and keep medical appointments and informyour Physician ahead of time when you must cancel.

8. Communicate openly with the Physician you choose

so you can develop a strong partnership based ontrust and cooperation.

9. Offer suggestions to improve the Claims Administra-tor Preferred Medical Plan.

10. Help the Claims Administrator to maintain accurateand current medical records by providing timely in-formation regarding changes in address, family statusand other health plan coverage.

11. Notify the Claims Administrator as soon as possibleif you are billed inappropriately or if you have anycomplaints.

12. Treat all Plan personnel respectfully and courteouslyas partners in good health care.

13. Pay your fees, Copayments and charges for non-covered services on time.

14. Follow the provisions of the Claims AdministratorsBenefits Management Program.


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TABLE OF CONTENTS

5

Prosthetic Appliances Benefits .............................................................................................................................................. 42Radiological and Nuclear Imaging Benefits .......................................................................................................................... 43Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) ......................................................................... 43 Skilled Nursing Facility Benefits .......................................................................................................................................... 43Speech Therapy Benefits ....................................................................................................................................................... 43Transplant Benefits Cornea, Kidney or Skin ...................................................................................................................... 44Transplant Benefits - Special ................................................................................................................................................. 44

PRINCIPAL LIMITATIONS,EXCEPTIONS,EXCLUSIONS AND REDUCTIONS .................................................................................... 44General Exclusions and Limitations ...................................................................................................................................... 44

Medical Necessity Exclusion................................................................................................................................................. 47Limitations for Duplicate Coverage ...................................................................................................................................... 48Exception for Other Coverage ............................................................................................................................................... 49Claims Review ...................................................................................................................................................................... 49Reductions Third Party Liability ........................................................................................................................................ 49Coordination of Benefits ....................................................................................................................................................... 50

TERMINATION OF BENEFITS ........................................................................................................................................................ 51Extension of Benefits ............................................................................................................................................................ 51

GROUP CONTINUATION COVERAGE AND INDIVIDUAL PLAN ....................................................................................................... 51Continuation of Group Coverage .......................................................................................................................................... 51

Continuation of Group Coverage for Members on Military Leave ....................................................................................... 53

Availability of the Claims Administrators Individual Plans ................................................................................................ 53

GENERAL PROVISIONS ................................................................................................................................................................ 53Liability of Participants in the Event of Non-Payment by the Claims Administrator ........................................................... 53

Independent Contractors ........................................................................................................................................................ 54Non-Assignability ................................................................................................................................................................. 54Plan Interpretation ................................................................................................................................................................. 54Confidentiality of Personal and Health Information .............................................................................................................. 54Access to Information............................................................................................................................................................ 54Right of Recovery ................................................................................................................................................................. 55

CUSTOMER SERVICE ................................................................................................................................................................... 55SETTLEMENT OF DISPUTES ......................................................................................................................................................... 55DEFINITIONS ............................................................................................................................................................................... 56

Plan Provider Definitions ...................................................................................................................................................... 56

All Other Definitions ............................................................................................................................................................. 58

SUPPLEMENT AOUTPATIENT PRESCRIPTION DRUG BENEFITS ............................................................................................... 64


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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 Benefit Booklet carefully to be sure you understand the Benefits, exclusions and general provisions. It isyour 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 Administratoroffices 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 Group Continua-tion 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 uponrenewal. 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 theBenefits of this Plan.

HCL America Inc. is the Employer. Blue Shield of California has been appointed the Claims Administrator. Blue Shield ofCalifornia 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 orobligation with respect to claims.

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.


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Preferred Summary of Benefits

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

Summary of Benefits Gold Plan

Member Calendar Year Deductible(Medical Plan Deductible)

Deductible Responsibility

Services by Preferred,

Participating, and Other

Providers

Services by Non-Preferred

and Non-Participating

Providers

Calendar Year MedicalDeductible$250 per Member /

$750 per Family$500 per Member /$1,000 per Family

Member Maximum Lifetime Benefits Maximum Claims Administrator Payment

Services by

Preferred, Participating, and

Other Providers

Services by Non-Preferred


Providers

Lifetime Benefit Maximum No maximum

Addi tional Payment(s)

Additional Payment(s) for Failure to Use the Benefits Management Program

Refer to the Benefits Management Program section for any additional payments which may apply.

Member Maximum Calendar YearCopayment Responsibility2

Member Maximum Calendar Year Copayment2, 3

Services by Preferred,

Participating, and

OtherProviders

Services by any combination

of Preferred, Participating,

Other Providers,Non-Preferred


Providers

Calendar Year Copayment Maximum$2,000 per Member /

$4,000 per Family$4,000 per Member /

$8,000 per Family


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Benefit Member Copayment3Services by

Preferred, Participating,

and Other Providers4

Services by

Non-Preferred and Non-

Participating Providers5

Acupuncture Benefits

Office visits by Doctors of Medicine who are doctors of internalmedicine, family doctors, general practitioners, gynecologists, ob-stetricians or pediatricians

$15 per visit $15 per visit

Office visits by other than Doctors of Medicine who are doctors ofinternal medicine, family doctors, general practitioners, gynecol-ogists, obstetricians or pediatricians


Allergy Testing and Treatment Benefits

Allergy serum purchased separately for treatment You pay nothing 40%

Office visits (includes visits for allergy serum injections) by Doc-tors of Medicine who are doctors of internal medicine, family doc-tors, general practitioners, gynecologists, obstetricians or pediatri-cians

$15 per visit 40%

Office visits (includes visits for allergy serum injections) by other

than Doctors of Medicine who are doctors of internal medicine,family doctors, general practitioners, gynecologists, obstetricians orpediatricians

$30 per visit 40%

Ambulance Benefits

Emergency or authorized transport 10% 10%

Ambulatory Surgery Center BenefitsNote: Participating Ambulatory Surgery Centers may not be availa-ble in all areas. Outpatient ambulatory surgery Services may also beobtained from a Hospital or an ambulatory surgery center that isaffiliated with a Hospital, and will be paid according to the HospitalBenefits (Facility Services) section of this Summary of Benefits.

Ambulatory surgery center Outpatient surgery facility Services 10% 40% of up to $350 per day

Ambulatory surgery center Outpatient surgery Physician Services 10% 40%


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Services by



Bariatric Surgery BenefitsAll bariatric surgery Services must be prior authorized, in writing,from the Claims Administrator's Medical Director. Prior authoriza-

tion is required for all Members, whether residents of a designatedor non-designated county.

Services by

Preferred and

Participating Providers

Services by



5

Bariatric Surgery Benefits for residents of designated counties

in CaliforniaAll bariatric surgery Services for residents of designated counties inCalifornia must be provided by a Preferred Bariatric Surgery Ser-vices Provider.Travel expenses may be covered under this Benefit for residents ofdesignated counties in California. See the Bariatric Surgery Benefitssection, the paragraphs under Bariatric Surgery Benefits for Resi-dents of Designated Counties in California, in Principal Benefitsand Coverages (Covered Services) for a description.

Hospital Inpatient Services $250 per admission plus10%

Not covered

Hospital Outpatient Services 10% Not covered

Physician bariatric surgery Services 10% Not covered

Bariatric Surgery Benefits for residents of non-designated coun-

ties in California

Hospital Inpatient Services $250 per admission plus10%

$250 per admission plus40% of up to $600 per day

Hospital Outpatient Services 10% 40% of up to $350 per day

Physician bariatric surgery Services 10% 40%

Chiropractic Benefits

Chiropractic ServicesUp to a Benefit maximum of 40 visits per Member per Calendar

YearIf your Plan has a Calendar Year medical Deductible, the number ofvisits start counting toward the maximum when Services are firstprovided even if the Calendar Year medical Deductible has notbeen met.


$15 per visit 40%


$30 per visit 40%


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Services by



Clinical Trial for Treatment of Cancer or Life-Threatening

Conditions Benefits

Clinical trial for Treatment of Cancer or Life-Threatening Condi-

tionsServices for routine patient care, not including research costs, willbe paid on the same basis and at the same Benefit levels as othercovered Services shown in this Summary of Benefits. The researchcosts may be covered by the clinical trial sponsor.

You pay nothing You pay nothing

Diabetes Care Benefits

Devices, equipment and supplies 10% 40%

Diabetes self-management training provided by Doctors of Medi-cine who are doctors of internal medicine, family doctors, generalpractitioners, gynecologists, obstetricians or pediatricians

$15 per visit 40%

Diabetes self-management training provided by other than Doctorsof Medicine who are doctors of internal medicine, family doctors,general practitioners, gynecologists, obstetricians or pediatricians

$30 per visit 40%

Dialysis Center Benefits

Dialysis ServicesNote: Dialysis Services may also be obtained from a Hospital.Dialysis Services obtained from a Hospital will be paid at the Pre-ferred or Non-Preferred level as specified under Hospital Benefits(Facility Services) of this Summary of Benefits.

10% 40% of up to $300 per day

Durable Medical Equipment Benefits

Breast pump You pay nothing 40%

Other Durable Medical Equipment 10% 40%

Emergency Room Benefits

Emergency room Physician ServicesNote: After Services have been provided, the Claims Administrator

may conduct a retrospective review. If this review determines thatServices were provided for a medical condition that a person wouldnot have reasonably believed was an emergency medical condition,Benefits will be paid at the applicable Preferred and Non-PreferredProvider levels as specified under Outpatient Physician ServicesBenefit in the Professional (Physician) Benefits in this Summary ofBenefits and will be subject to any Calendar Year medical Deducti-ble.

You pay nothing You pay nothing

Emergency room Services not resulting in admissionNote: After Services have been provided, the Claims Administratormay conduct a retrospective review. If this review determines thatServices were provided for a medical condition that a person wouldnot have reasonably believed was an emergency medical condition,

Benefits will be paid at the applicable Preferred and Non-PreferredProvider levels as specified under Hospital Benefits (Facility Ser-vices), Outpatient Services for treatment of illness or illness, or in-jury, radiation therapy, chemotherapy and necessary supplies in thisSummary of Benefits and will be subject to any Calendar Yearmedical Deductible.


Emergency room Services resulting in admission(Billed as part of Inpatient Hospital Services)

$250 per admission plus10%

$250 per admission plus10%8


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Services by



Family Planning and Infertility BenefitsNote: Copayments listed in this section are for Outpatient PhysicianServices only. If Services are performed at a facility (Hospital, am-

bulatory surgery center, etc.), the facility Copayment listed underthe appropriate facility Benefit in this Summary of Benefits willalso apply, except for insertion and/or removal of intrauterine de-vice (IUD), intrauterine device (IUD), and tubal ligation by Pre-ferred Providers.

Counseling and consulting(Including Physician office visits for diaphragm fitting, injectablecontraceptives, or implantable contraceptives)

You pay nothing 40%

Diaphragm fitting procedure You pay nothing 40%

Elective abortion 10% 40%

Implantable contraceptives You pay nothing 40%

Infertility BenefitsInfertility Services Diagnosis and treatment of cause of Infertility

(in-vitro fertilization and artificial insemination not covered)Infertility office visits by Doctors of Medicine who are doctors ofinternal medicine, family doctors, general practitioners, gynecol-ogists, obstetricians or pediatricians

$15 per visit Not covered

Infertility office visits by other than Doctors of Medicine who aredoctors of internal medicine, family doctors, general practitioners,gynecologists, obstetricians or pediatricians

$30 per visit Not covered

Injectable contraceptives You pay nothing 40%

Insertion and/or removal of intrauterine device (IUD) You pay nothing 40%

Intrauterine device (IUD) You pay nothing 40%

Tubal ligation You pay nothing 40%

Vasectomy 10% 40%


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Services by



Home Health Care Benefits

Home health care agency Services (including home visits by anurse, home health aide, medical social worker, physical therapist,

speech therapist, or occupational therapist)Up to a maximum of 100 visits per Calendar Year per Member byhome health care agency providersIf your Plan has a Calendar Year medical Deductible, the number ofvisits start counting toward the maximum when Services are firstprovided even if the Calendar Year medical Deductible has notbeen met.

10% Not covered

Medical supplies 10% Not covered9

Home Infusion/Home Injectable Therapy Benefits

Hemophilia home infusion Services provided by a hemophilia infu-sion provider and prior authorized by the Plan. Includes blood fac-tor product.

10% Not covered

Home infusion/home intravenous injectable therapy provided by a

Home Infusion Agency (Home infusion agency visits are not sub-ject to the visit limitation under Home Health Care Benefits.)Note: Home non-intravenous self-administered injectable drugs arecovered under the Outpatient Prescription Drug Benefit if selectedas an optional Benefit by your Employer, and are described in aSupplement included with this booklet.

10% Not covered

Home visits by an infusion nurseHome infusion agency nursing visits are not subject to the HomeHealth Care Calendar Year visit limitation

10% Not covered

Hospice Program BenefitsCovered Services for Members who have been accepted into anapproved Hospice ProgramAll Hospice Program Benefits must be prior authorized by the Plan

and must be received from a Participating Hospice Agency.24-hour Continuous Home Care 10% Not covered10

General Inpatient care 10% Not covered1

Inpatient Respite Care 10% Not covered1

Pre-hospice consultation 10% Not covered1

Routine home care 10% Not covered1


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Services by



Hospital Benefits (Facility Services)

Inpatient Emergency Facility Services $250 per admission plus10%


Inpatient non-Emergency Facility ServicesSemi-private room and board, and Medically Necessary Servicesand supplies, including Subacute Care.For bariatric surgery Services for residents of designated counties,see the Bariatric Surgery Benefits for Residents of DesignatedCounties in California section.Prior authorization required by the Plan.(See Non-Preferred payment example below) Example: 1 day in theHospital, up to the $600 Allowable Amount times (x) 40% Partici-pant contribution = Participant payment of up to $240.



Inpatient Medically Necessary skilled nursing Services includingSubacute CareUp to a maximum of 120 days per Calendar Year per Member ex-

cept when received through a Hospice Program provided by a Par-ticipating Hospice Agency. This day maximum is a combined Ben-efit maximum for all skilled nursing services whether rendered in aHospital or a free-standing Skilled Nursing Facility.If your Plan has a Calendar Year medical Deductible, the number ofdays start counting toward the maximum when Services are firstprovided even if the Calendar Year medical Deductible has notbeen met.


Inpatient Services to treat acute medical complications of detoxifi-cation



Outpatient diagnostic testing X-ray, diagnostic examination andclinical laboratory ServicesNote: These Benefits are for diagnostic, non-Preventive Health Ser-vices. For Benefits for Preventive Health Services, see the Preven-tive Health Benefits section of this Summary of Benefits.(See Non-Preferred payment example below)

Example: 1 day in the Hospital, up to the $350 Allowable Amounttimes (x)40% Participant contribution=Participant payment of up to $140

You pay nothing 40% of up to $350 per day

Outpatient dialysis Services(See Non-Preferred payment example below)



Outpatient Services for surgery and necessary supplies(See Non-Preferred payment example below)

Example: 1 day in the Hospital, up to the $350 Allowable Amount

times (x)40% Participant contribution=Participant payment of up to $140


Outpatient Services for treatment of illness or injury, radiation ther-apy, chemotherapy and necessary supplies(See Non-Preferred payment example below)




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Services by



Medical Treatment of the Teeth, Gums, Jaw Joints or Jaw

Bones BenefitsTreatment of gum tumors, damaged natural teeth resulting from

Accidental Injury, TMJ as specifically stated and orthognathic sur-gery for skeletal deformity(Be sure to read the Principal Benefits and Coverages (CoveredServices) section for a complete description.)

Ambulatory Surgery Center Outpatient Surgery facility Services 10% 40% of up to $350 per day

Inpatient Hospital Services $250 per admission plus10%



$15 per visit 40%


$30 per visit 40%

Outpatient department of a Hospital 10% 40% of up to $350 per day

Mental Health and Substance Abuse Benefits11

Services by


Services by Non-


Inpatient Hospital Services $250 per admission plus10%

$250 per admission plus40% of up to $600 perday13

Inpatient Professional (Physician) Services 10% 40%

Outpatient Mental Health and Substance Abuse Services, IntensiveOutpatient Care and Outpatient electroconvulsive therapy (ECT)

$15 per visit14 40%14

Outpatient Partial Hospitalization 10%1 40% per episode of up to$350 per day15

Psychological testing You pay nothing 40%

Transcranial Magnetic Stimulation $15 per visit 40%

Nutritional Evaluation and Counseling Benefits

Nutritional evaluation and counseling visits by Doctors of Medicinewho are doctors of internal medicine, family doctors, general practi-tioners, gynecologists, obstetricians or pediatricians

$15 per visit 40%

Nutritional evaluation and counseling visits by other than Doctorsof Medicine who are doctors of internal medicine, family doctors,general practitioners, gynecologists, obstetricians or pediatricians

$30 per visit 40%

Note: Benefits are provided for nutritional evaluation and counsel-ing when diet is part of the medical management of a documentedorganic disease up to a maximum of 3 visits per Member per Cal-endar Year


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Services by



Orthotics Benefits

Office visits by Doctors of Medicine who are doctors of internalmedicine, family doctors, general practitioners, gynecologists, ob-

stetricians or pediatricians

$15 per visit 40%


$30 per visit 40%

Orthotic equipment and devices 10% 40%

Outpatient Prescription Drug Benefits

Outpatient Prescription Drug coverage if selected as an optionalBenefit by your Employer, is described in a Supplement includedwith this booklet.

Outpatient X-ray, Pathology, and Laboratory BenefitsNote: Benefits in this section are for diagnostic, non-PreventiveHealth Services. For Benefits for Preventive Health Services, seethe Preventive Health Benefits section of this Summary of Benefits.

For Benefits for diagnostic radiological procedures such as CTscans, MRIs, MRAs, PET scans, etc. see the Radiological and Nu-clear Imaging Benefits section of this Summary of Benefits.Outpatient diagnostic X-ray, pathology, diagnostic examination andclinical laboratory Services, including mammography andPapanicolaou test.

Outpatient Laboratory Center or Outpatient Radiology CenterNote: Preferred Laboratory Centers and Preferred Radiology Cen-ters may not be available in all areas. Laboratory and radiologyServices may also be obtained from a Hospital or from a laboratoryand radiology center that is affiliated with a Hospital. Laboratoryand radiology Services obtained from a Hospital or Hospital-affiliated laboratory and radiology center will be paid at the Pre-

ferred or Non-Preferred level as specified under Hospital Benefits(Facility Services) of this Summary of Benefits.

You pay nothing , 1 40% , 1

PKU Related Formulas and Special Food Products Benefits

PKU Related Formulas and Special Food Products 10% 10%

Podiatric Benefits

Podiatric Services provided by a licensed doctor of podiatric medi-cine

$30 per visit 40%

Pregnancy and Maternity Care BenefitsNote: Routine newborn circumcision is only covered as described inthe Principal Benefits and Coverages (Covered Services) section.When covered, Services will pay as any other surgery as noted inthis Summary of Benefits.

All necessary Inpatient Hospital Services for normal delivery, Ce-sarean section, and complications of pregnancy



Prenatal and postnatal Physician office visits(including prenatal diagnosis of genetic disorders of the fetus bymeans of diagnostic procedures in cases of high-risk pregnancy)

10% 40%

Preventive Health Benefits

Preventive Health ServicesSee the description of Preventive Health Services in the Definitionssection for more information.

You pay nothing 40%

Immunizations for the purpose of business travel You pay nothing 40%


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Services by



Professional (Physician) Benefits

Inpatient Physician ServicesFor bariatric surgery Services for residents of designated counties,

see the Bariatric Surgery Benefits for Residents of DesignatedCounties in California section

10% 40%

Outpatient Physician Services, other than an office setting You pay nothing 40%

Physician home visits by Doctors of Medicine who are doctors ofinternal medicine, family doctors, general practitioners, gynecol-ogists, obstetricians or pediatricians

$15 per visit 40%

Physician home visits by other than Doctors of Medicine who aredoctors of internal medicine, family doctors, general practitioners,gynecologists, obstetricians or pediatricians

$30 per visit 40%


$15 per visit 40%

Office visits by other than Doctors of Medicine who are doctors of

internal medicine, family doctors, general practitioners, gynecol-ogists, obstetricians or pediatricians

$30 per visit 40%

Note: For other Services with the office visit, you may incur anadditional Benefit Copayment as listed for that Service within thisSummary of Benefits. This additional Benefit Copayment may besubject to the Plan's medical Deductible.Additionally, certain Physician office visits may have a Copaymentamount that is different from the one stated here. For those Physi-cian office visits, the Copayment will be as stated elsewhere in thisSummary of Benefits.

Prosthetic Appliances Benefits

Office visits by Doctors of Medicine who are doctors of internalmedicine, family doctors, general practitioners, gynecologists, ob-

stetricians or pediatricians

$15 per visit 40%


$30 per visit 40%

Prosthetic equipment and devices 10% 40%

Radiological and Nuclear Imaging BenefitsNote: Benefits in this section are for diagnostic, non-PreventiveHealth Services. For Benefits for Preventive Health Services, seethe Preventive Health Benefits section of this Summary of Benefits.Outpatient non-emergency radiological and nuclear imaging proce-dures including CT scans, MRIs, MRAs, PET scans, and cardiacdiagnostic procedures utilizing nuclear medicine.Prior authorization required by the Plan.

Outpatient department of a HospitalPrior authorization required by the Plan.

10% 40% of up to $350 perday16

Radiology CenterNote: Preferred Radiology Centers may not be available in all areas.Prior authorization required by the Plan.

You pay nothing1 40%1


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Services by



Rehabilitation Benefits (Physical, Occupational and Respirato-

ry Therapy)Rehabilitation Services by a physical, occupational, or respiratory

therapist in the following settings:Office location by Doctors of Medicine who are doctors of internalmedicine, family doctors, general practitioners, gynecologists, ob-stetricians or pediatricians

$15 per visit4, 7 40%

Office location by other than Doctors of Medicine who are doctorsof internal medicine, family doctors, general practitioners, gynecol-ogists, obstetricians or pediatricians

$30 per visit , 40%

Outpatient department of a Hospital $30 per visit , 40% of up to $350 per day

Rehabilitation unit of a Hospital for Medically Necessary daysIn an Inpatient facility, this Copayment is billed as part of InpatientHospital Services



Skilled Nursing Facility rehabilitation unit for Medically Necessarydays.

Up to a maximum of 120 days per Calendar Year per Member ex-cept when received through a Hospice Program provided by a Par-ticipating Hospice Agency. This day maximum is a combined Ben-efit maximum for all skilled nursing services whether rendered in aHospital or a free-standing Skilled Nursing Facility.If your Plan has a Calendar Year medical Deductible, the number ofdays start counting toward the maximum when Services are firstprovided even if the Calendar Year medical Deductible has notbeen met.

10%4 10%4

Skilled Nursing Facility Benefits

Services by a free-standing Skilled Nursing FacilityUp to a maximum of 120 days per Calendar Year per Member ex-cept when received through a Hospice Program provided by a Par-

ticipating Hospice Agency. This day maximum is a combined Ben-efit maximum for all skilled nursing services whether rendered in aHospital or a free-standing Skilled Nursing Facility.If your Plan has a Calendar Year medical Deductible, the number ofdays start counting toward the maximum when Services are firstprovided even if the Calendar Year medical Deductible has notbeen met.

10%4 10%4


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Services by



Speech Therapy BenefitsSpeech Therapy Services by a Doctor of Medicine or licensedspeech pathologist or licensed speech therapist in the following

settings:Office location by Doctors of Medicine who are doctors of inter-nal medicine, family doctors, general practitioners, gynecologists,obstetricians or pediatricians

$15 per visit7 40%

Office location by other than Doctors of Medicine who are doc-tors of internal medicine, family doctors, general practitioners, gy-necologists, obstetricians or pediatricians

$30 per visit 40%

Outpatient department of a Hospital $30 per visit , 40% of up to $350 per day

Rehabilitation unit of a Hospital for Medically Necessary daysIn an Inpatient facility, this Copayment is billed as part of InpatientHospital Services



Skilled Nursing Facility rehabilitation unit for Medically Necessarydays.

Up to a maximum of 60 days per Calendar Year per Member exceptwhen received through a Hospice Program provided by a Participat-ing Hospice Agency. This day maximum is a combined Benefitmaximum for all skilled nursing services whether rendered in aHospital or a free-standing Skilled Nursing Facility.If your Plan has a Calendar Year medical Deductible, the number ofdays start counting toward the maximum when Services are firstprovided even if the Calendar Year medical Deductible has notbeen met.

10%4 10%4

Transplant Benefits - Cornea, Kidney or SkinOrgan Transplant Benefits for transplant of a cornea, kidney or skin

Hospital Services $250 per admission plus10%


Professional (Physician) Services 10% 40%Transplant Benefits - SpecialNote: The Claims Administrator requires prior authorization fromthe Claims Administrator's Medical Director for all Special Trans-plant Services. Also, all Services must be provided at a SpecialTransplant Facility designated by the Claims Administrator.Please see the Transplant Benefits - Special portion of the PrincipalBenefits (Covered Services) section in the Benefit Booklet for im-portant information on this benefit.

Facility Services in a Special Transplant Facility $250 per admission plus10%

Not covered

Professional (Physician) Services 10% Not covered

Note: Authorized travel expenses in connection with an organ

transplant are covered up to a Plan payment maximum of $10,000per transplant.


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Summary of Benefits

Footnotes1 Copayments or Coinsurance paid for Covered Services will accrue to a Member Calendar Year Deductible (Medical

Plan Deductible) except for the following Covered Services:Acupuncture Services;

Breast pump as listed under Durable Medical Equipment Benefits by Preferred Providers;Chiropractic Services by Preferred Providers;Diabetes Self-Management Training by Preferred Providers;Emergency room Facility Services not resulting in an admission;Family planning counseling and consultation Services, diaphragm fitting procedure, injectable contraceptives by aPhysician, implantable contraceptives, insertion and/or removal of intrauterine device, intrauterine device, and tuballigation by Preferred Providers;Preferred Physician office and home visits: However, covered Services received during or in connection with a Pre-ferred Physician office or home visit are subject to the Calendar Year Deductible;Preventive health Benefits by Preferred Providers;Services provided under the Outpatient Prescription Drug Benefits Supplement if selected as an optional Benefit byyour Employer.

The Calendar Year Deductible is included in the Member maximum Calendar Year Copayment.Copayments for Covered Services accrue to the Member maximum Calendar Year Copayment, except Copaymentsfor:

Additional and reduced payments under the Benefits Management Program;Charges by Non-Preferred Providers in excess of covered amounts;Charges in excess of specified benefit maximums;Services provided under the Outpatient Prescription Drug Benefits Supplement if selected as an optional Benefit byyour Employer;Infertility Benefits;

Note: Copayments and charges for Services not accruing to the maximum Calendar Year Copayment responsibilitycontinue to be the Member's responsibility after the Calendar Year Copayment maximum is reached.

3 Copayments are calculated based on the Allowable Amount, unless otherwise specified.

4 Other Providers as defined in the Definitions section of this booklet, are not Participating or Preferred Providers. For

Covered Services from Other Providers you are responsible for any Copayment and any charges above the Allowable

Amount.5 For Covered Services from Non-Preferred and Non-Participating Providers you are responsible for a Copayment and allcharges above the Allowable Amount.

6 The Copayment will be calculated based upon the provider's billed charges or the amount the provider has otherwise

agreed to accept as payment in full from the Plan, whichever is less.7 If billed by your provider, you will also be responsible for an office visit Copayment.

8 If you receive emergency room Services that are determined to not be Emergency Services and which result in admis-

sion as an Inpatient to a Non-Preferred Hospital, you will be responsible for a Non-Preferred Hospital Inpatient Ser-vices Copayment.

9 Services from a Non-Participating Home Health Agency or Non-Participating Home Infusion Agency are not covered

unless prior authorized by the Plan. When Services are authorized, your Copayment will be calculated at the Participat-ing Provider level based upon the agreed upon rate between the Plan and the agency.

10 Services from a Non-Participating Hospice Agency are not covered unless prior authorized by the Plan. When Services

are authorized, your Copayment will be calculated at the Participating Provider level based upon the agreed upon ratebetween the Plan and the agency.

11 Prior authorization is required for all non-Emergency or non-Urgent Services except that no prior authorization is re-

quired for Professional (Physical) Office Visit.12 For Services by Non-Participating Providers you are responsible for a Copayment and all charges above the Allowable

Amount.13 For Emergency Services received from a Non-Participating Hospital, your Copayment will be the Participating Provid-

er level, based on the Allowable Amount.14

This Copayment includes both Outpatient facility and Professional (Physician) Services.


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15 For Outpatient Partial Hospitalization Services, an episode of care is the date from which the patient is admitted to the

Partial Hospitalization Program to the date the patient is discharged or leaves the Partial Hospitalization Program. AnyServices received between these two dates would constitute the episode of care. If the patient needs to be readmitted ata later date, this would constitute another episode of care.

16 A Copayment will apply for each provider and date of service.


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INTRODUCTION

If you have questions about your Benefits, contact theClaims Administrator before Hospital or medical Servicesare received.

This Plan is designed to reduce the cost of health care to you,the Participant. In order to reduce your costs, much greaterresponsibility is placed on you.

You should read your Benefit Bookletcarefully. Your book-let tells you which services are covered by your health Planand which are excluded. It also lists your Copayment andDeductible responsibilities.

When you need health care, present your Claims Adminis-trator ID card to your Physician, Hospital, or other licensedhealthcare provider. Your ID card has your Participant andgroup numbers on it. Be sure to include these numbers onall claims you submit to the Claims Administrator.

In order to receive the highest level of Benefits, you shouldassure that your provider is a Preferred Provider (see the

Preferred Providers section).You are responsible for following the provisions shown inthe Benefits Management Program section of this booklet,including:

1. You or your Physician must obtain the Claims Admin-istrator approval at least 5 working days before Hospi-tal or Skilled Nursing Facility admissions for all non-Emergency Inpatient Hospital or Skilled Nursing Fa-cility Services. (See the Preferred Providers sectionfor information.)

2. You or your Physician must notify the Claims Adminis-trator within 24 hours or by the end of the first business

day following emergency admissions, or as soon as it isreasonably possible to do so.

3. You or your Physician must obtain prior authorizationin order to determine if contemplated services are cov-ered. See Prior Authorization in the Benefits Man-agement Program section for a listing of Services re-quiring prior authorization.

Failure to meet these responsibilities may result in your incur-ring a substantial financial liability. Some Services may notbe covered unless prior review and other requirements aremet.

Note: The Claims Administrator will render a decision on

all requests for prior authorization within 5 business daysfrom receipt of the request. The treating provider will benotified of the decision within 24 hours followed by writtennotice to the provider and Participant within 2 business daysof the decision. For urgent services in situations in whichthe routine decision making process might seriously jeop-ardize the life or health of a Member or when the Member isexperiencing severe pain, the Claims Administrator willrespond as soon as possible to accommodate the Memberscondition not to exceed 72 hours from receipt of the request.

PLEASE READ THE FOLLOWING INFORMATION SOYOU WILL KNOW FROM WHOM OR WHAT GROUPOF PROVIDERS HEALTH CARE MAY BE OBTAINED.

PREFERRED PROVIDERS

The Claims Administrator Gold Plan is specifically de-signed for you to use the Claims Administrator PreferredProviders. Preferred Providers include certain Physicians,Hospitals, Alternate Care Services Providers, and other Pro-viders. Preferred Providers are listed in the Preferred Pro-vider Directories. All Claims Administrator PhysicianMembers are Preferred Providers. So are selected Hospitalsin your community. Many other healthcare professionals,including dentists, podiatrists, optometrists, audiologists,licensed clinical psychologists and licensed marriage andfamily therapists are also Preferred Providers. They are alllisted in your Preferred Provider Directories.

To determine whether a provider is a Preferred Provider,consult the Preferred Provider Directory. You may also ver-ify this information by accessing the Claims Administrators

Internet site located at http://www.blueshieldca.com, or bycalling Customer Service at the telephone number shown onthe last page of this booklet. Note: A Preferred Providersstatus may change. It is your obligation to verify whether thePhysician, Hospital or Alternate Care Services provider youchoose is a Preferred Provider, in case there have been anychanges since your Preferred Provider Directory was pub-lished.

Note: In some instances services are covered only if ren-dered by a Preferred Provider. Using a Non-Preferred Pro-vider could result in lower or no payment by the ClaimsAdministrator for services.

Preferred Providers agree to accept the Claims Administra-tor's payment, plus your payment of any applicable Deduct-ibles, Copayments, or amounts in excess of specified Bene-fit maximums, as payment in full for covered Services, ex-cept for the Deductibles, Copayments, and amounts in ex-cess of specified Benefit maximums, or as provided underthe Exception for Other Coverage provision and the Reduc-tions section regarding Third Party Liability. This is not trueof non-Preferred Providers.

You are not responsible to Participating and Preferred Pro-viders for payment for covered Services, except for the De-ductibles, Copayments, and amounts in excess of specifiedBenefit maximums, and except as provided under the Ex-

ception for Other Coverage provision.The Claims Administrator contracts with Hospitals andPhysicians to provide Services to Members for specifiedrates. This contractual arrangement may include incentivesto manage all services provided to Members in an appropri-ate manner consistent with the contract. If you want to knowmore about this payment system, contact Customer Serviceat the number provided on the back page of this booklet.

If you go to a Non-Preferred Provider, the Claims Adminis-trator's payment for a Service by that Non-Preferred Provid-


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er may be substantially less than the amount billed. You areresponsible for the difference between the amount theClaims Administrator pays and the amount billed by Non-Preferred Providers. It is therefore to your advantage to obtainmedical and Hospital Services from Preferred Providers.

Payment for Emergency Services rendered by a Physicianor Hospital who is not a Preferred Provider will be based onthe Allowable Amount but will be paid at the Preferred lev-el of benefits. You are responsible for notifying the ClaimsAdministrator within 24 hours, or by the end of the firstbusiness day following emergency admission at a Non-Preferred Hospital, or as soon as it is reasonably possible todo so.

Directories of Preferred Providers located in your area havebeen provided to you. Extra copies are available from theClaims Administrator. If you do not have the directories,please contact the Claims Administrator immediately andrequest them at the telephone number listed on the last pageof this booklet.

CONTINUITY OF CARE BY A TERMINATEDPROVIDER

Members who are being treated for acute conditions, seriouschronic conditions, pregnancies (including immediate post-partum care), or terminal illness; or who are children frombirth to 36 months of age; or who have received authoriza-tion from a now-terminated provider for surgery or anotherprocedure as part of a documented course of treatment canrequest completion of care in certain situations with a pro-vider who is leaving the Claims Administrator providernetwork. Contact Customer Service to receive informationregarding eligibility criteria and the policy and procedurefor requesting continuity of care from a terminated provider.

FINANCIAL RESPONSIBILITY FOR CONTINUITY OFCARE SERVICES

If a Member is entitled to receive Services from a terminat-ed provider under the preceding Continuity of Care provi-sion, the responsibility of the Member to that provider forServices rendered under the Continuity of Care provisionsshall be no greater than for the same Services rendered by aPreferred Provider in the same geographic area.

SUBMITTING A CLAIM FORM

Preferred Providers submit claims for payment after their

Services have been received. You or your Non-PreferredProviders also submit claims for payment after Serviceshave been received.

You are paid directly by the Claims Administrator if Ser-vices are rendered by a Non-Preferred Provider. Paymentsto you for covered Services are in amounts identical to thosemade directly to providers. Requests for payment must besubmitted to the Claims Administrator within 1 year afterthe month Services were provided. Special claim forms arenot necessary, but each claim submission must contain your

name, home address, Plan number, Participant's number, acopy of the provider's billing showing the Services ren-dered, dates of treatment and the patient's name. The ClaimsAdministrator will notify you of its determination within 30days after receipt of the claim.

To submit a claim for payment, send a copy of your item-ized bill, along with a completed Claims Administrator Par-ticipant's Statement of Claim form to the Claims Adminis-trator service center listed on the last page of this booklet.

Claim forms are available on the Claims AdministratorsInternet site located at http://www.blueshieldca.com or youmay call Customer Service at the number listed on the lastpage of this booklet to ask for forms. If necessary, you mayuse a photocopy of the Claims Administrator claim form.

Be sure to send in a claim for all covered Services even ifyou have not yet met your Calendar Year Deductible. TheClaims Administrator will keep track of the Deductible foryou. The Claims Administrator uses an Explanation of Ben-efits to describe how your claim was processed and to in-form you of your financial responsibility.

ELIGIBILITY

1. To enroll and continue enrollment, a Member mustmeet all of the eligibility requirements of the Plan.

If you are an Employee, you are eligible for coverage as aParticipant the day following the date you complete thewaiting period established by your Employer. Your spouseor Domestic Partner and all your Dependent children areeligible at the same time.

When you decline coverage for yourself or your Dependentsduring the initial enrollment period and later request en-

rollment, you and your Dependents will be considered to beLate Enrollees. When Late Enrollees decline enrollmentduring the initial enrollment period, they will be eligible theearlier of 12 months from the date of the request for enroll-ment or at the Employers next Open Enrollment Period.The Claims Administrator will not consider applications forearlier effective dates.

You and your Dependents will not be considered to be LateEnrollees if either you or your Dependents lose coverage un-der a previous employers health plan and you apply for cov-erage under this Plan within 31 days of the date of loss ofcoverage. You will be required to furnish the Claims Admin-istrator written proof of the loss of coverage.

Newborn infants of the Participant, spouse, or his or herDomestic Partner will be eligible immediately after birth forthe first 31 days. A child placed for adoption will be eligibleimmediately upon the date the Participant, spouse or Do-mestic Partner has the right to control the childs healthcare. Enrollment requests for children who have been placedfor adoption must be accompanied by evidence of the Par-ticipants, spouses or Domestic Partners right to controlthe childs health care. Evidence of such control includes ahealth facility minor release report, a medical authorization


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form or a relinquishment form. In order to have coveragecontinue beyond the first 31 days without lapse, an applica-tion must be submitted to and received by the Claims Ad-ministrator within 31 days from the date of birth or place-ment for adoption of such Dependent.

A child acquired by legal guardianship will be eligible onthe date of the court ordered guardianship, if an applicationis submitted within 31 days of becoming eligible.

You may add newly acquired Dependents and yourself tothe Plan by submitting an application within 31 days fromthe date of acquisition of the Dependent:

a. to continue coverage of a newborn or child placed foradoption;

b. to add a spouse after marriage, or add a Domestic Part-ner after establishing a domestic partnership;

c. to add yourself and spouse following the birth of anewborn or placement of a child for adoption;

d. to add yourself and spouse after marriage;

e. to add yourself and your newborn or child placed foradoption, following birth or placement for adoption.

A completed health statement may be required with the ap-plication. Coverage is never automatic; an application isalways required.

If both partners in a marriage or domestic partnership areboth eligible to be Participants, children may be eligible andmay be enrolled as a Dependent of either parent, but notboth.

Enrolled Dependent children who would normally lose theireligibility under this Plan solely because of age, but who are

incapable of self-sustaining employment by reason of aphysically or mentally disabling injury, illness, or condition,may have their eligibility extended under the followingconditions: (1) the child must be chiefly dependent upon theEmployee for support and maintenance, and (2) the Em-ployee must submit a Physicians written certification ofsuch disabling condition. The Claims Administrator or theEmployer will notify you at least 90 days prior to the datethe Dependent child would otherwise lose eligibility. Youmust submit the Physicians written certification within 60days of the request for such information by the Employer orby the Plan. Proof of continuing disability and dependencymust be submitted by the Employee as requested by theClaims Administrator but not more frequently than 2 years

after the initial certification and then annually thereafter.

Subject to the requirements described under the Continua-tion of Group Coverage provision in this booklet, if appli-cable, an Employee and his or her Dependents will be eligi-ble to continue group coverage under this Plan when cover-age would otherwise terminate.

2. If a Member commits any of the following acts, theywill immediately lose eligibility to continue enrollment:

a. Abusive or disruptive behavior which:

(1) threatens the life or well-being of Plan person-nel, or providers of services;

(2) substantially impairs the ability of the ClaimsAdministrator to arrange for services to theMember; or

(3) substantially impairs the ability of providers ofServices to furnish Services to the Member or

to other patients.

b. Failure or refusal to provide the Claims Adminis-trator access to documents and other informationnecessary to determine eligibility or to administerbenefits under the Plan.

3. Employer eligibility The Employer must meet speci-fied Employer eligibility, participation and contributionrequirements to be eligible for this group Plan. See yourEmployer for further information.

EFFECTIVE DATE OF COVERAGE

Coverage will become effective for Employees and De-pendents who enroll during the initial enrollment period at12:01 a.m. Pacific Time on the eligibility date establishedby your Employer.

If, during the initial enrollment period, you have includedyour eligible Dependents on your application to the ClaimsAdministrator, their coverage will be effective on the samedate as yours. If application is made for Dependent cover-age within 31 days after you become eligible, their effectivedate of coverage will be the same as yours.

If you or your Dependent is a Late Enrollee, your coveragewill become effective the earlier of 12 months from the dateyou made a written request for coverage or at the Employ-ers next Open Enrollment Period. The Claims Administra-tor will not consider applications for earlier effective dates.

If you declined coverage for yourself and your Dependentsduring the initial enrollment period because you or yourDependents were covered under another employer healthplan, and you or your Dependents subsequently lost cover-age under that plan, you will not be considered a Late En-rollee. Coverage for you and your Dependents under thisPlan will become effective on the date of loss of coverage,provided you enroll in this Plan within 31 days from thedate of loss of coverage. You will be required to furnish theClaims Administrator written evidence of loss of coverage.

If you declined enrollment during the initial enrollment pe-riod and subsequently acquire Dependents as a result ofmarriage, establishment of domestic partnership, birth, orplacement for adoption, you may request enrollment foryourself and your Dependents within 31 days. The effectivedate of enrollment for both you and your Dependents willdepend on how you acquire your Dependent(s):

1. For marriage or domestic partnership, the effective datewill be the first day of the first month following receiptof your request for enrollment;


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2. For birth, the effective date will be the date of birth;

3. For a child placed for adoption, the effective date willbe the date the Participant, spouse, or Domestic Partnerhas the right to control the childs health care.

Once each Calendar Year, your Employer may designate atime period as an annual Open Enrollment Period. Duringthat time period, you and your Dependents may transfer

from another health plan sponsored by your Employer to theGold Plan. A completed enrollment form must be forwardedto the Claims Administrator within the Open EnrollmentPeriod. Enrollment becomes effective on the anniversarydate of this Plan following the annual Open Enrollment Pe-riod.

Any individual who becomes eligible at a time other thanduring the annual Open Enrollment Period (e.g., newborn,child placed for adoption, child acquired by legal guardian-ship, new spouse or Domestic Partner, newly hired or newlytransferred Employees) must complete an enrollment formwithin 31 days of becoming eligible.

Coverage for a newborn child will become effective on thedate of birth. Coverage for a child placed for adoption willbecome effective on the date the Participant, spouse or Do-mestic Partner has the right to control the childs healthcare, following submission of evidence of such control (ahealth facility minor release report, a medical authorizationform or a relinquishment form). In order to have coveragecontinue beyond the first 31 days without lapse, a writtenapplication must be submitted to and received by the ClaimsAdministrator within 31 days. An application may also besubmitted electronically, if available. A Dependent spousebecomes eligible on the date of marriage. A Domestic Part-ner becomes eligible on the date a domestic partnership isestablished as set forth in the Definitions section of thisbooklet. A child acquired by legal guardianship will be eli-gible on the date of the court ordered guardianship.

If a court has ordered that you provide coverage for yourspouse, Domestic Partner or Dependent child under yourhealth benefit Plan, their coverage will become effectivewithin 31 days of presentation of a court order by the dis-trict attorney, or upon presentation of a court order or re-quest by a custodial party, as described in Section 3751.5 ofthe Family Code.

If you or your Dependents voluntarily discontinued cover-age under this Plan and later request reinstatement, you oryour Dependents will be covered the earlier of 12 months

from the date of request for reinstatement or at the Employ-ers next Open Enrollment Period.

If this Plan provides Benefits within 60 days of the date ofdiscontinuance of the previous group health plan that was ineffect with your Employer;

1. you and all your Dependents who were validly coveredunder the previous group health plan on the date of dis-continuance, will be eligible under this Plan except that,

2. if you or your Dependents were enrolled in the previousgroup health plan for less than 6 months and were To-tally Disabled on the date of discontinuance of the pre-vious group health plan and were entitled to an exten-sion of benefits under Section 1399.62 of the CaliforniaHealth and Safety Code or Section 10128.2 of the Cali-fornia Insurance Code, you or your Dependents will notbe entitled to any benefits under this Plan for services

or expenses directly related to any condition whichcaused such Total Disability for a period not to exceed 6months.

RENEWAL OF PLAN DOCUMENT

The Claims Administrator will offer to renew thePlan Document except in the following instances:

1. non-payment of fees (see Termination ofBenefits);

2. fraud, misrepresentations or omissions;

3. failure to comply with the Claims Administra-tor's applicable eligibility, participation or con-tribution rules;

4. termination of plan type by the Claims Ad-ministrator;

5. Employer relocates outside of California;

6. association membership ceases.

All groups will renew subject to the above.

SERVICES FOR EMERGENCY CAREThe Benefits of this Plan will be provided for covered Ser-vices received anywhere in the world for the emergencycare of an illness or injury.

Members who reasonably believe that they have an emer-gency medical condition which requires an emergency re-sponse are encouraged to appropriately use the 911 emer-gency response system where available.

Note: For the lowest out-of-pocket expenses, covered non-Emergency Services or emergency room follow-up Services(e.g., suture removal, wound check, etc.) should be receivedin a Participating Physicians office.

UTILIZATION REVIEW

State law requires that health plans disclose to Participantsand health plan providers the process used to authorize ordeny health care services under the Plan.

The Claims Administrator has completed documentation ofthis process (Utilization Review), as required under Sec-tion 1363.5 of the California Health and Safety Code.


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To request a copy of the document describing this Utiliza-tion Review process, call the Customer Service Departmentat the number listed on the last page of this booklet.

SECOND MEDICAL OPINION POLICY

If you have a question about your diagnosis, or believe thatadditional information concerning your condition would be

helpful in determining the most appropriate plan of treat-ment, you may make an appointment with another Physicianfor a second medical opinion. Your attending Physician mayalso offer to refer you to another Physician for a secondopinion.

Remember that the second opinion visit is subject to all PlanBenefit limitations and exclusions.

HEALTH EDUCATION ANDHEALTH PROMOTION SERVICES

Health education and health promotion Services providedby the Claims Administrators Center for Health and Well-ness offer a variety of wellness resources including, but notlimited to: a Participant newsletter and a prenatal healtheducation program.

RETAIL-BASED HEALTH CLINICS

Retail-based health clinics are Outpatient facilities, usuallyattached or adjacent to retail stores, pharmacies, etc., whichprovide limited, basic medical treatment for minor healthissues. They are staffed by nurse practitioners under thedirection of a Physician and offer services on a walk-in ba-sis. Covered Services received from retail-based health clin-ics will be paid on the same basis and at the same Benefit

levels as other covered Services shown in the Summary ofBenefits. Retail-based health clinics may be found in thePreferred Provider Directory or the Online Physician Direc-tory located at http://www.blueshieldca.com. See the Pre-ferred Providers section for information on the advantagesof choosing a Preferred Provider.

THE CLAIMSADMINISTRATOR ONLINE

The Claims Administrators Internet site is located athttp://www.blueshieldca.com. Members with Internet accessand a Web browser may view and download healthcare in-formation.

BENEFITS MANAGEMENT PROGRAM

The Claims Administrator has established the BenefitsManagement Program to assist you, your Dependents, orprovider in identifying the most appropriate and cost-effective course of treatment for which certain Benefits willbe provided under this health Plan and for determiningwhether the services are Medically Necessary. However,you, your Dependents and provider make the final decisionconcerning treatment. The Benefits Management Programincludes: prior authorization review for certain services;

emergency admission notification; Hospital Inpatient re-view, discharge planning, and case management if deter-mined to be applicable and appropriate by the Claims Ad-ministrator.

Certain portions of the Benefits Management Program alsocontain Additional and Reduced Payment requirements foreither not contacting the Claims Administrator or not fol-lowing the Claims Administrators recommendations. Fail-ure to contact the Plan for authorization of services listed inthe sections below or failure to follow the Plans recom-mendations may result in reduced payment or non-paymentif the Claims Administrator determines the service was not acovered Service. Please read the following sections thor-oughly so you understand your responsibilities in referenceto the Benefits Management Program. Remember that allprovisions of the Benefits Management Program also applyto your Dependents.

The Claims Administrator requires prior authorization forselected Inpatient and Outpatient services, supplies andDurable Medical Equipment; admission into an approved

Hospice Program; and certain radiology procedures. Pre-admission review is required for all Inpatient Hospital andSkilled Nursing Facility services (except for EmergencyServices*).

*See the paragraph entitled Emergency Admission Notifica-tion later in this section for notification requirements.

By obtaining prior authorization for certain services prior toreceiving services, you and your provider can verify: (1) Ifthe Claims Administrator considers the proposed treatmentMedically Necessary, (2) if Plan Benefits will be providedfor the proposed treatment, and (3) if the proposed setting isthe most appropriate as determined by the Claims Adminis-

trator. You and your provider may be informed about Ser-vices that could be performed on an Outpatient basis in aHospital or Outpatient Facility.

PRIORAUTHORIZATION

For services and supplies listed in the section below, you oryour provider can determine before the service is providedwhether a procedure or treatment program is a Covered Ser-vice and may also receive a recommendation for an alterna-tive Service. Failure to contact the Claims Administrator asdescribed below or failure to follow the recommendationsof the Claims Administrator for Covered Services will resultin a reduced payment per procedure as described in the sec-

tion entitled Additional and Reduced Payments for Failureto Use the Benefits Management Program.

For Services other than those listed in the sections below,you, your Dependents or provider should consult the Princi-pal Benefits and Coverages (Covered Services) section ofthis booklet to determine whether a service is covered.

You or your Physician must call the Customer Service tele-phone number indicated on the back of the Members iden-tification card for prior authorization for the services listedin this section except for the Outpatient radiological proce-


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dures described in item 10. below. For prior authorizationfor Outpatient radiological procedures, you or your Physi-cian must call 1-888-642-2583.

The Claims Administrator requires prior authorization forthe following services:

1. Admission into an approved Hospice Program as speci-fied under Hospice Program Benefits in the Covered

Services section.

2. Clinical Trial for Cancer Benefits.

Members who have been accepted into an approvedclinical trial for cancer as defined under the CoveredServices section must obtain prior authorization fromthe Claims Administrator in order for the routine pa-tient care delivered in a clinical trial to be covered.

Failure to obtain prior authorization or to follow the rec-ommendations of the Claims Administrator for HospiceProgram Benefits and Clinical Trial for Cancer Benefitsabove will result in non-payment of services by the ClaimsAdministrator.

3. Select injectable drugs, except injectable contraceptives(prior authorization not required) administered in thePhysician office setting.*

*Prior authorization is based on Medical Necessity, ap-propriateness of therapy, or when effective alternativesare available.

Note: Your Preferred or Non-Preferred Physician mustobtain prior authorization for select injectable drugsadministered in the Physicians office. Failure to obtainprior authorization or to follow the recommendations ofthe Claims Administrator for select injectable drugsmay result in non-payment by the Claims Administratorif the service is determined not to be a covered Service;in that event you may be financially responsible forservices rendered by a Non-Preferred Physician.

4. Home Health Care Benefits from Non-Preferred Pro-viders.

5. Home Infusion/Home Injectable Therapy Benefits fromNon-Preferred Providers.

6. Durable Medical Equipment Benefits, including but notlimited to motorized wheelchairs, insulin infusionpumps, and Continuous Glucose Monitoring Systems(CGMS), except breast pumps (prior authorization not

required).7. Reconstructive Surgery.

8. Arthroscopic surgery of the temporomandibular joint(TMJ) Services.

9. Hemophilia home infusion products and Services.

Failure to obtain prior authorization or to follow the rec-ommendations of the Claims Administrator for:

injectable drugs administered in the Physician officesetting,

Home Health Care Benefits from Non-Preferred Pro-viders,

Home Infusion/Home Injectable Therapy Benefits fromNon-Preferred Providers,

Durable Medical Equipment Benefits,

Reconstructive Surgery,

arthroscopic surgery of the TMJ services,

and

hemophilia home infusion products and supplies

as described above may result in non-payment of servicesby the Claims Administrator.

10. The following radiological procedures when performedin an Outpatient setting on a non-emergency basis:

CT (Computerized Tomography) scans, MRIs (Magnet-ic Resonance Imaging), MRAs (Magnetic ResonanceAngiography), PET (Positron Emission Tomography)scans, and any cardiac diagnostic procedure utilizingNuclear Medicine.

Prior authorization is not required for these radiologicalservices when obtained outside of California. See theOut-Of-Area Program: The BlueCard Program sec-tion of this booklet for an explanation of how paymentis made for out of state services.

11. Special Transplant Benefits as specified under Trans-plant Benefits - Special in the Covered Services sec-tion.

12. All bariatric surgery.

13. Hospital and Skilled Nursing Facility admissions (see

the subsequent Hospital and Skilled Nursing FacilityAdmissions section for more information).

14. Medically Necessary dental and orthodontic Servicesthat are an integral part of Reconstructive Surgery forcleft palate procedures.

Failure to obtain prior authorization or to follow the rec-ommendations of the Claims Administrator for:

Outpatient radiological procedures as specified above,

Special Transplant Benefits,

all bariatric surgery,

Hospital and Skilled Nursing Facility admissions, and

Dental and orthodontic Services that are an integral partof Reconstructive Surgery for cleft palate procedures.

as described above will result in a reduced payment as de-scribed in the Additional and Reduced Payments for Failureto Use the Benefits Management Program section or mayresult in non-payment if the Claims Administrator deter-mines that the service is not a covered Service.

Other specific services and procedures may require priorauthorization as determined by the Claims Administrator. A


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list of services and procedures requiring prior authorizationcan be obtained by your provider by going tohttp://www.blueshieldca.com or by calling the CustomerService telephone number indicated on the back of theMembers identification card.

HOSPITAL AND SKILLED NURSING FACILITYADMISSIONS

Prior authorization must be obtained from the Claims Ad-ministrator for all Hospital and Skilled Nursing Facilityadmissions (except for admissions required for EmergencyServices). Included are hospitalizations for continuing Inpa-tient Rehabilitation and skilled nursing care, transplants,bariatric surgery, and Inpatient Mental Health and Sub-stance Abuse Services if this health plan provides thesebenefits.

Prior Authorization for Other than Mental Healthand Substance Abuse Admissions

Whenever a Hospital or Skilled Nursing Facility admission

is recommended by your Physician, you or your Physicianmust contact the Claims Administrator at the Customer Ser-vice telephone number indicated on the back of the Mem-bers identification card at least 5 business days prior to theadmission. However, in case of an admission for Emergen-cy Services, the Claims Administrator should receive emer-gency admission notification within 24 hours or by the endof the first business day following the admission, or as soonas it is reasonably possible to do so. The Claims Adminis-trator will discuss the Benefits available, review the medicalinformation provided and may recommend that to obtain thefull Benefits of this health Plan that the Services be per-formed on an Outpatient basis.

Examples of procedures that may be recommended to beperformed on an Outpatient basis if medical conditions donot indicate Inpatient care include:

1. Biopsy of lymph node, deep axillary;

2. Hernia repair, inguinal;

3. Esophagogastroduodenoscopy with biopsy;

4. Excision of ganglion;

5. Repair of tendon;

6. Heart catheterization;

7. Diagnostic bronchoscopy;

8. Creation of arterial venous shunts (for hemodialysis).

Failure to contact the Claims Administrator as described orfailure to follow the recommendations of the Claims Ad-ministrator will result in an additional payment per admis-sion as described in the Additional and Reduced Paymentsfor Failure to Use the Benefits Management Program sec-tion or may result in reduction or non-payment by theClaims Administrator if it is determined that the admissionis not a covered Service.*

*Note: For admissions for special transplant Benefits andfor bariatric Services for residents of designated counties,failure to receive prior authorization in writing and/or fail-ure to have the procedure performed at the Claims Adminis-trator designated facility will result in non-payment of ser-vices by the Claims Administrator. See Transplant Benefitsand Bariatric Surgery Benefits for Residents of DesignatedCounties in California under the Covered Services section

for details.

Prior Authorization for Inpatient Mental Health andSubstance Abuse Services

All Inpatient Mental Health and Substance Abuse Servicesexcept for Emergency Services, must be prior authorized bythe Claims Administrator.

For an admission for Emergency Mental Health or Sub-stance Abuse Services, the Claims Administrator shouldreceive emergency admission notification within 24 hoursor by the end of the first business day following the admis-sion, or as soon as it is reasonably possible to do so, or theParticipant may be responsible for the additional payment asdescribed below.

For prior authorization of Inpatient Mental Health or Sub-stance Abuse Services call the Customer Service telephonenumber indicated on the back of the Members identifica-tion card.

Failure to contact the Claims Administrator as describedabove or failure to follow the recommendations of theClaims Administrator will result in an additional paymentper admission as described in the Additional and ReducedPayments for Failure to Use the Benefits Management Pro-gram section or may result in reduction or non-payment bythe Claims Administrator if it is determined that the admis-

sion is not a covered Service.

Note: The Claims Administrator will render a decision onall requests for prior authorization within 5 business daysfrom receipt of the request. The treating provider will benotified of the decision within 24 hours followed by writtennotice to the provider and Participant within 2 business daysof the decision. For urgent services in situations in whichthe routine decision making process might seriously jeop-ardize the life or health of a Member or when the Member isexperiencing severe pain, the Claims Administrator willrespond as soon as possible to accommodate the Memberscondition not to exceed 72 hours from receipt of the request.

EMERGENCYADMISSION NOTIFICATION

If you are admitted for Emergency Services, the ClaimsAdministrator should receive emergency admission notifica-tion within 24 hours or by the end of the first business dayfollowing the admission, or as soon as it is reasonably pos-sible to do so, or you may be responsible for the additionalpayment as described under the Additional and ReducedPayments for Failure to Use the Benefits Management Pro-gram section.


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HOSPITAL INPATIENT REVIEW

The Claims Administrator monitors Inpatient stays. Thestay may be extended or reduced as warranted by your con-dition, except in situations of maternity admissions forwhich the length of stay is 48 hours or less for a normal,vaginal delivery or 96 hours or less for a Cesarean sectionunless the attending Physician, in consultation with the

mother, determines a shorter Hospital length of stay is ade-quate. Also, for mastectomies or mastectomies with lymphnode dissections, the length of Hospital stays will be deter-mined solely by your Physician in consultation with you.When a determination is made that the Member no longerrequires the level of care available only in an Acute CareHospital, written notification is given to you and your Doc-tor of Medicine. You will be responsible for any Hospitalcharges Incurred beyond 24 hours of receipt of notification.

DISCHARGE PLANNING

If further care at home or in another facility is appropriate fol-lowing discharge from the Hospital, the Claims Administrator

may work with you, your Physician and the Hospital dis-charge planners to determine whether benefits are availableunder this Plan to cover such care.

CASE MANAGEMENT

The Benefits Management Program may also include casemanagement, which provides assistance in making the mostefficient use of Plan Benefits. Individual case managementmay also arrange for alternative care benefits in place ofprolonged or repeated hospitalizations, when it is deter-mined to be appropriate through the Claims Administratorreview. Such alternative care benefits will be available onlyby mutual consent of all parties and, if approved, will not

exceed the Benefit to which you would otherwise have beenentitled under this Plan. The Claims Administrator is notobligated to provide the same or similar alternative carebenefits to any other person in any other instance. The ap-proval of alternative benefits will be for a specific period oftime and will not be construed as a waiver of the ClaimsAdministrators right to thereafter administer this h

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