Certificated and Management Employees Access+ HMO plan

Access+ HMO plan for dual coverage Trio ACO HMO plan

Trio ACO HMO plan for dual coverage Shield Spectrum PPO plan

Shield Spectrum PPO plan for dual coverage

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Santa Ana Unified School District Custom Access+ HMO Certificated Management Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California Effective: July 1, 2017 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Highlights: A description of the prescription drug coverage is provided separately 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 Professional (Physician) Benefits

Physician and specialist office visits (note: a woman may self-refer to an OB/GYN or family practice physician in her personal physician's medical group or IPA for OB/GYN services)

$20 per visit

Teladoc consultation $5 per consultation Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services No Charge Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

No Charge

Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections $20 per visit

Access+ SpecialistSM Benefits 1 Office visit, examination or other consultation (self-referred office visits and consultations only) $30 per visit

Preventive Health Benefits Preventive health services (as required by applicable Federal and California law) No Charge

OUTPATIENT FACILITY SERVICES Outpatient surgery performed at a free-standing ambulatory surgery center No Charge Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center

No Charge

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

No Charge

Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services No Charge Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

No Charge

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

Inpatient Skilled Nursing Benefits 2, 3 (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations)

Free-standing skilled nursing facility No Charge Skilled nursing unit of a hospital No Charge

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)

$150 per visit

Emergency room physician services No Charge AMBULANCE SERVICES

Emergency or authorized transport (ground or air) No Charge 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 (member share is based on allowed charges) No Charge

MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES 4, 5 Inpatient hospital services No Charge Residential care No Charge Inpatient physician services No Charge Routine outpatient mental health and substance use disorder services (includes professional/physician visits)

$5 per visit

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

No Charge

HOME HEALTH SERVICES Home health care agency services 2 Coverage limited to 100 visits per member per calendar year. $20 per visit Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency

No Charge

HOSPICE PROGRAM BENEFITS Routine home care No Charge Inpatient respite care No Charge 24-hour continuous home care No Charge Short-term inpatient care for pain and symptom management No Charge

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

No Charge

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

No Charge

FAMILY PLANNING AND INFERTILITY BENEFITS Counseling, consulting, and education (Includes insertion of IUD, as well as injectable and implantable contraceptives for women)

No Charge

Infertility services (member cost share is based upon allowed charges) (diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT)

50%

Tubal ligation No Charge Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

No Charge

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

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

$20 per visit

DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for testing supplies see Outpatient Prescription Drug Benefits)

No Charge

Diabetes self-management training $20 per visit

HEARING AID BENEFITS Hearing aid instrument and ancillary equipment (plan ayment maximum up to $2,000 every 24 months)

No Charge

Audiological exams $20 per visit URGENT CARE BENEFITS

Urgent care services outside your personal physician service area within California $20 per visit Urgent care services outside of California (BlueCard® Program) $20 per visit

OPTIONAL BENEFITS Optional dental, vision, hearing aid, infertility, chiropractic or acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately.

1 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.

2 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the plan deductible has been met.

3 Inpatient skilled nursing services are limited to 100 preauthorized days during a benefit period except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on inpatient skilled nursing services is a combined maximum between skilled nursing services provided in a hospital unit and skilled nursing services provided in a skilled nursing facility (SNF).

4 Mental health and substance use disorder services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) - using MHSA participating providers. 5 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit

details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers. Plan designs may be modified to ensure compliance with state and Federal requirements. A16205 (1/17) 20618 DC050817

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Santa Ana Unified School District Custom Access+ HMO Certified & Management Dual Coverage Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California Effective: July 1, 2017 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Highlights: A description of the prescription drug coverage is provided separately 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 Professional (Physician) Benefits

Physician and specialist office visits (note: a woman may self-refer to an OB/GYN or family practice physician in her personal physician's medical group or IPA for OB/GYN services)

No Charge

Teladoc consultation $5 per consultation Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services No Charge Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

No Charge

Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections No Charge

Access+ SpecialistSM Benefits 1 Office visit, examination or other consultation (self-referred office visits and consultations only) $30 per visit

Preventive Health Benefits Preventive health services (as required by applicable Federal and California law) No Charge

OUTPATIENT FACILITY SERVICES Outpatient surgery performed at a free-standing ambulatory surgery center No Charge Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center No Charge Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits")

No Charge

Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services No Charge Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

No Charge

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)

No Charge

Inpatient Skilled Nursing Benefits 2, 3 (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations)

Free-standing skilled nursing facility No Charge Skilled nursing unit of a hospital No Charge

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)

No Charge

Emergency room physician services No Charge AMBULANCE SERVICES

Emergency or authorized transport (ground or air) No Charge 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 (member share is based on allowed charges) No Charge

MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES 4, 5 Inpatient hospital services No Charge Residential care No Charge Inpatient physician services No Charge Routine outpatient mental health and substance use disorder services (includes professional/physician visits)

No Charge

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

No Charge

HOME HEALTH SERVICES Home health care agency services 2 Coverage limited to 100 visits per member per calendar year. No Charge Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency

No Charge

HOSPICE PROGRAM BENEFITS Routine home care No Charge Inpatient respite care No Charge 24-hour continuous home care No Charge Short-term inpatient care for pain and symptom management No Charge

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

No Charge

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

No Charge

FAMILY PLANNING AND INFERTILITY BENEFITS Counseling, consulting, and education (Includes insertion of IUD, as well as injectable and implantable contraceptives for women)

No Charge

Infertility services (member cost share is based upon allowed charges) (diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT)

50%

Tubal ligation No Charge Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

No Charge

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)

No Charge

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

No Charge

DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for testing supplies see Outpatient Prescription Drug Benefits)

No Charge

Diabetes self-management training No Charge HEARING AID BENEFITS

Hearing aid instrument and ancillary equipment (plan payment up to $2,000 every 24 months) No Charge Audiological exams No Charge

URGENT CARE BENEFITS Urgent care services outside your personal physician service area within California No Charge Urgent care services outside of California (BlueCard® Program) No Charge

OPTIONAL BENEFITS Optional dental, vision, hearing aid, infertility, chiropractic or acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately.

1 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.

2 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the plan deductible has been met.

3 Inpatient skilled nursing services are limited to 100 preauthorized days during a benefit period except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on inpatient skilled nursing services is a combined maximum between skilled nursing services provided in a hospital unit and skilled nursing services provided in a skilled nursing facility (SNF).

4 Mental health and substance use disorder services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) - using MHSA participating providers. 5 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit

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

Plan designs may be modified to ensure compliance with state and Federal requirements. A16205 (1/17) 20628 DC050917

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Santa Ana Unified School District Custom Trio ACO HMO Certificated & Management Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California Effective: July 1, 2017 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Highlights: A description of the prescription drug coverage is provided separately This plan is available only in certain California counties and cities "Service Area" as described in the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this plan. This HMO plan also utilizes an Accountable Care Organization (ACO) for its provider network. Except for Emergency Services, Urgent Services when the Member is out of the Service Area, or when prior authorized, all services must be obtained through the Member’s Personal Physician and within the ACO provider network to be covered. This health plan uses the ACO HMO provider network. 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 Professional (Physician) Benefits

Physician and specialist office visits (note: a woman may self-refer to an OB/GYN or family practice physician in her personal physician's medical group or IPA for OB/GYN services)

$20 per visit

Teladoc consultation $5 per consultation Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services No Charge Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

No Charge

Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections $20 per visit

Access+ SpecialistSM Benefits 1 Office visit, examination or other consultation (self-referred office visits and consultations only) $30 per visit

Preventive Health Benefits Preventive health services (as required by applicable Federal and California law) No Charge

OUTPATIENT FACILITY SERVICES Outpatient surgery performed at a free-standing ambulatory surgery center No Charge Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center

No Charge

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

No Charge

Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services No Charge Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

No Charge

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

Inpatient Skilled Nursing Benefits 2, 3 (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations)

Free-standing skilled nursing facility No Charge Skilled nursing unit of a hospital No Charge

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)

$150 per visit

Emergency room physician services No Charge AMBULANCE SERVICES

Emergency or authorized transport (ground or air) No Charge

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 (member share is based on allowed charges) No Charge

MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES 4, 5 Inpatient hospital services No Charge Residential care No Charge Inpatient physician services No Charge Routine outpatient mental health and substance use disorder services (includes professional/physician visits)

$5 per visit

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

No Charge

HOME HEALTH SERVICES Home health care agency services 2 Coverage limited to 100 visits per member per calendar year. $20 per visit Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency

No Charge

HOSPICE PROGRAM BENEFITS Routine home care No Charge Inpatient respite care No Charge 24-hour continuous home care No Charge Short-term inpatient care for pain and symptom management No Charge

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

No Charge

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

No Charge

FAMILY PLANNING AND INFERTILITY BENEFITS Counseling, consulting, and education (Includes insertion of IUD, as well as injectable and implantable contraceptives for women)

No Charge

Infertility services (member cost share is based upon allowed charges) (diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT)

50%

Tubal ligation No Charge Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

No Charge

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

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

$20 per visit

DIABETES CARE BENEFITS Hearing aid instrument and ancillary equipment (plan payment up to $2,000 every 24 months) No Charge Audiological exams $20 per visit

HEARING AID BENEFITS Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for testing supplies see Outpatient Prescription Drug Benefits)

No Charge

Diabetes self-management training $20 per visit URGENT CARE BENEFITS

Urgent care services outside your personal physician service area within California $20 per visit Urgent care services outside of California (BlueCard® Program) $20 per visit

OPTIONAL BENEFITS Optional dental, vision, hearing aid, infertility, chiropractic or acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately.

1 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.

2 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the plan deductible has been met.

3 Inpatient skilled nursing services are limited to 100 preauthorized days during a benefit period except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on inpatient skilled nursing services is a combined maximum between skilled nursing services provided in a hospital unit and skilled nursing services provided in a skilled nursing facility (SNF).

4 Mental health and substance use disorder services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) - using MHSA participating providers. 5 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit

details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers. Plan designs may be modified to ensure compliance with state and Federal requirements. A47048 (1/17) 20630 DC050917

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Santa Ana Unified School District Custom Trio ACO HMO Certified & Management Dual Coverage Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California Effective: July 1, 2017 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Highlights: A description of the prescription drug coverage is provided separately This plan is available only in certain California counties and cities "Service Area" as described in the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this plan. This HMO plan also utilizes an Accountable Care Organization (ACO) for its provider network. Except for Emergency Services, Urgent Services when the Member is out of the Service Area, or when prior authorized, all services must be obtained through the Member’s Personal Physician and within the ACO provider network to be covered. This health plan uses the ACO HMO provider network. 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 Professional (Physician) Benefits

Physician and specialist office visits (note: a woman may self-refer to an OB/GYN or family practice physician in her personal physician's medical group or IPA for OB/GYN services)

No Charge

Teladoc consultation $5 per consultation Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services No Charge Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

No Charge

Allergy Testing and Treatment Benefits Allergy testing, treatment and serum injections No Charge

Access+ SpecialistSM Benefits 1 Office visit, examination or other consultation (self-referred office visits and consultations only) $30 per visit

Preventive Health Benefits Preventive health services (as required by applicable Federal and California law) No Charge

OUTPATIENT FACILITY SERVICES Outpatient surgery performed at a free-standing ambulatory surgery center No Charge Outpatient surgery performed in a hospital or a hospital affiliated ambulatory surgery center

No Charge

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

No Charge

Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services No Charge Radiological and nuclear imaging (CT scans, MRIs, MRAs, PET scans and cardiac diagnostic procedures utilizing nuclear medicine)

No Charge

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)

No Charge

Inpatient Skilled Nursing Benefits 2, 3 (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations)

Free-standing skilled nursing facility No Charge Skilled nursing unit of a hospital No Charge

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)

No Charge

Emergency room physician services No Charge AMBULANCE SERVICES

Emergency or authorized transport (ground or air) No Charge

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 (member share is based on allowed charges) No Charge

MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES 4, 5 Inpatient hospital services No Charge Residential care No Charge Inpatient physician services No Charge Routine outpatient mental health and substance use disorder services (includes professional/physician visits)

No Charge

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

No Charge

HOME HEALTH SERVICES Home health care agency services 2 Coverage limited to 100 visits per member per calendar year. No Charge Home infusion/home injectable therapy and infusion nursing visits provided by a home infusion agency

No Charge

HOSPICE PROGRAM BENEFITS Routine home care No Charge Inpatient respite care No Charge 24-hour continuous home care No Charge Short-term inpatient care for pain and symptom management No Charge

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

No Charge

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

No Charge

FAMILY PLANNING AND INFERTILITY BENEFITS Counseling, consulting, and education (Includes insertion of IUD, as well as injectable and implantable contraceptives for women)

No Charge

Infertility services (member cost share is based upon allowed charges) (diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT)

50%

Tubal ligation No Charge Vasectomy (an additional facility copayment may apply when services are rendered in a hospital or outpatient surgery center)

No Charge

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)

No Charge

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

No Charge

DIABETES CARE BENEFITS Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for testing supplies see Outpatient Prescription Drug Benefits)

No Charge

Diabetes self-management training No Charge HEARING AID BENEFITS

Hearing aid instrument and ancillary equipment (plan payment up to $2,000 every 24 months) No Charge Audiological exams No Charge

URGENT CARE BENEFITS Urgent care services outside your personal physician service area within California No Charge Urgent care services outside of California (BlueCard® Program) No Charge

OPTIONAL BENEFITS Optional dental, vision, hearing aid, infertility, chiropractic or acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately.

1 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.

2 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the plan deductible has been met.

3 Inpatient skilled nursing services are limited to 100 preauthorized days during a benefit period except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on inpatient skilled nursing services is a combined maximum between skilled nursing services provided in a hospital unit and skilled nursing services provided in a skilled nursing facility (SNF).

4 Mental health and substance use disorder services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) - using MHSA participating providers. 5 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit

details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers. Plan designs may be modified to ensure compliance with state and Federal requirements. A47048 (1/17) 20631 DC051017

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Santa Ana Unified School District Chiropractic Benefits Additional coverage for your HMO Plans Blue Shield Chiropractic Care coverage lets you self-refer to a network of more than 4,000 licensed chiropractors. Benefits are provided through a contract with American Specialty Health Plans of California, Inc. (ASH Plans).

How the Program Works You can visit any participating chiropractor from the ASH Plans network without a referral from your HMO or POS Personal Physician. Simply call a participating provider to schedule an initial exam.

At the time of your first visit, you’ll present your Blue Shield identification card and pay only your copayment. Because participating chiropractors bill ASH Plans directly, you’ll never have to file claim forms.

If you need further treatment, the participating chiropractor will submit a proposed treatment plan to ASH Plans and obtain the necessary authorization from ASH Plans to continue treatment up to the calendar year maximum of 30 visits.

What’s Covered The plan covers medically necessary chiropractic services including:

Initial and subsequent examinations Office visits and adjustments (subject to annual limits) Adjunctive therapies X-rays (chiropractic only)

Benefit Plan Design

Calendar year Maximum 30 Visits

Calendar year Deductible None

Calendar year Chiropractic Appliances Benefit1,2 $50

Covered Services Member Copayment

Chiropractic Services $10

Out-of-network Coverage None

1. Chiropractic appliances are covered up to a maximum of $50 in a calendar year as authorized by ASH Plans.

2. As authorized by ASH Plans, this allowance is applied toward the purchase of items determined necessary, such as supports, collars,

pillows, heel lifts, ice packs, cushions, orthotics, rib belts and home traction units.

Friendly Customer Service Helpful ASH Plans Member Services representatives are available at (800) 678-9133 Monday through Friday from 6 a.m. to 5 p.m. to answer questions, assist with problems, or help locate a participating chiropractor. This document is only a summary for informational purposes. It is not a contract. Please refer to the Evidence of Coverage and the Group Health Service Agreement for the exact terms and conditions of coverage.

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Santa Ana Unified School District

Custom PPO Certificated & Management Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California

Effective: July 1, 2017

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Highlights: A description of the prescription drug coverage is provided separately

Participating Providers 1 Non-Participating Providers 2

Calendar Year Medical Deductible (participating and non-participating deductibles accrue separately)

$300 per individual / $600 per family

$600 per individual / $1,200 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 amount)

$2,800 per individual / $5,600 per family

$4,600 per individual / $9,200 per family

Lifetime Benefit Maximum None

Covered Services Member Copayment

OUTPATIENT PROFESSIONAL SERVICES Participating Providers 1 Non-Participating Providers 2 Professional (Physician) Benefits

Physician and specialist office visits $20 per visit (not subject to the calendar year

medical deductible)

40%

Teladoc consultation $5 per consultation Not Covered 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 Benefits 3

Preventive health services (as required by applicable Federal and California law) No Charge (not subject to the calendar year

medical deductible)

Not Covered

OUTPATIENT FACILITY SERVICES

Outpatient surgery performed at a free-standing ambulatory surgery center

20% 40% up to $1,500 per day 4

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

20% 40% up to $1,500 per day 4

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

20% 40% up to $1,500 per day 4

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

20% 40% up to $1,500 per day 4

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

20% 40% up to $1,500 per day 4

Bariatric surgery 5 (prior authorization is required; medically necessary surgery for weight loss, for morbid obesity only)

20% 40% up to $1,500 per day 4

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% up to $1,500 per day 6

Bariatric surgery 5 (prior authorization is required; medically necessary surgery for weight loss is for morbid obesity only)

20% 40% up to $1,500 per day 6

Inpatient Skilled Nursing Benefits 7 , 8 Coverage limited to 100 days per member per benefit period combined with hospital/free-standing skilled nursing facility.

Free-standing skilled nursing facility 20% 20% 8 Skilled nursing unit of a hospital 20% 40% up to $1,500 per day 6

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)

$150 per visit (not subject to the calendar year

medical deductible)

$150 per visit (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)

40%

Other durable medical equipment 20% 40% MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES 9, 10 MHSA Participating

Providers 1 MHSA Non-Participating

Providers 2

Inpatient hospital services 20% 40% up to $1,500 per day 6 Residential care 20% 40% up to $1,500 per day 6 Inpatient physician services 20% 40% Routine outpatient mental health and substance use disorder services (includes professional/physician visits)

$5 per visit (not subject to the calendar year

medical deductible)

40%

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

20% 40%

HOME HEALTH SERVICES Participating Providers 1 Non-Participating Providers 2

Home health care agency services 7 Coverage limited to 100 visits per member per calendar year.

20% Not Covered 11

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

20% Not Covered 11

HOSPICE PROGRAM BENEFITS

Routine home care No Charge (not subject to the calendar year

medical deductible)

Not Covered 11

Inpatient respite care No Charge (not subject to the calendar year

medical deductible)

Not Covered 11

24-hour continuous home care No Charge (not subject to the calendar year

medical deductible)

Not Covered 11

Short-term inpatient care for pain and symptom management No Charge (not subject to the calendar year

medical deductible)

Not Covered 11

CHIROPRACTIC BENEFITS 7

Chiropractic spinal manipulation Coverage limited to 50 visits per calendar year. 20% 40% ACUPUNCTURE BENEFITS 7

Acupuncture services 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 (may be 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%

FAMILY PLANNING BENEFITS

Counseling, consulting, and education (includes injectable and implantable contraceptives for women)

No Charge (not subject to the calendar year

medical deductible)

Not Covered

Intrauterine Device (Insertion and removal of IUD) No Charge (not subject to the calendar year

medical deductible)

40%

Tubal ligation No Charge (not subject to the calendar year

medical deductible)

Not Covered

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

20% Not Covered

DIABETES CARE BENEFITS

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

20% 40%

Diabetes self-management training $20 per visit (not subject to the calendar year

medical deductible)

40%

HEARING AIDS BENEFITS

Hearing aid instrument and ancillary equipment (plan payment up to $2,000 every 24 months)

No Charge (not subject to the calendar year

medical deductible)

40%

Audioligical exams $20 per visit (not subject to the calendar year

medical deductible)

40%

CARE OUTSIDE OF CALIFORNIA 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

OPTIONAL BENEFITS Optional dental, vision, infertility, and hearing aid benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately.

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 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.

4 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 $1,500 per day. Members are responsible for 40% of this $1,500 per day, and all charges in excess of $1,500 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.

5 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties (“Designated Counties”), bariatric surgery services are covered only when performed at designated contracting bariatric surgery

facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric

services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a

designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of

Coverage for further details.

6 The maximum allowed charges for non-emergency hospital services received from a non-participating hospital is $1,500 per day. Members are responsible for 40% of this $1,500 per day, and all charges in excess of $1,500 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.

7 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 plan calendar year medical deductible has been met.

8 Services may require prior authorization. When services are prior authorized, members pay the participating provider amount.

9 Mental health and substance use disorder services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) - using MHSA participating and MHSA non-participating providers. Only mental health and substance use disorder services rendered by MHSA participating providers are administered by the MHSA. Mental

health and substance use disorder services rendered by non-MHSA participating providers are administered by Blue Shield.

10 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers.

11 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.

Plan designs may be modified to ensure compliance with state and Federal requirements. A44629 (1/17) 20637 DC051017; 053117

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Santa Ana Unified School District

Custom PPO Certified & Management Dual Coverage Benefit Summary (For groups of 101 and above) (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California

Effective: July 1, 2017

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Highlights: A description of the prescription drug coverage is provided separately

Participating Providers 1 Non-Participating Providers 2

Calendar Year Medical Deductible (participating and non-participating deductibles accrue separately)

$300 per individual / $600 per family

$600 per individual / $1,200 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 amount)

$2,800 per individual / $5,600 per family

$4,600 per individual / $9,200 per family

Lifetime Benefit Maximum None

Covered Services Member Copayment

OUTPATIENT PROFESSIONAL SERVICES Participating Providers 1 Non-Participating Providers 2 Professional (Physician) Benefits

Physician and specialist office visits No Charge (not subject to the calendar year

medical deductible)

30%

Teladoc consultation $5 per consultation Not Covered Outpatient diagnostic x-ray, imaging, pathology, laboratory and other testing services

No Charge (not subject to the calendar year

medical deductible)

30%

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

20% 30%

Allergy Testing and Treatment Benefits

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

10% 30%

Preventive Health Benefits 3

Preventive health services (as required by applicable Federal and California law) No Charge (not subject to the calendar year

medical deductible)

30%

OUTPATIENT FACILITY SERVICES

Outpatient surgery performed at a free-standing ambulatory surgery center

10% 30% up to $1,500 per day 4

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

10% 30% up to $1,500 per day 4

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

10% 30% up to $1,500 per day 4

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

No Charge (not subject to the calendar year

medical deductible)

30% up to $1,500 per day 4

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

No Charge (not subject to the calendar year

medical deductible)

30% up to $1,500 per day 4

Bariatric surgery 5 (prior authorization is required; medically necessary surgery for weight loss, for morbid obesity only)

10% 30% up to $1,500 per day 4

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% up to $1,500 per day 6

Bariatric surgery 5 (prior authorization is required; medically necessary surgery for weight loss is for morbid obesity only)

10% 30% up to $1,500 per day 6

Inpatient Skilled Nursing Benefits 7 , 8 Coverage limited to 100 days per member per benefit period combined with hospital/free-standing skilled nursing facility.

Free-standing skilled nursing facility 10% 10% 8 Skilled nursing unit of a hospital 10% 30% up to $1,500 per day 6

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)

No Charge (not subject to the calendar year

medical deductible)

No Charge (not subject to the calendar year

medical deductible) 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)

30%

Other durable medical equipment 20% 30% MENTAL HEALTH AND SUBSTANCE USE DISORDER SERVICES 9, 10 MHSA Participating

Providers 1 MHSA Non-Participating

Providers 2

Inpatient hospital services 10% 30% up to $1,500 per day 6 Residential care 10% 30% up to $1,500 per day 6 Inpatient physician services 10% 30% Routine outpatient mental health and substance use disorder services (includes professional/physician visits)

No Charge (not subject to the calendar year

medical deductible)

30%

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

No Charge (not subject to the calendar year

medical deductible)

30%

HOME HEALTH SERVICES Participating Providers 1 Non-Participating Providers 2

Home health care agency services 7 Coverage limited to 100 visits per member per calendar year.

20% Not Covered 11

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

20% Not Covered 11

HOSPICE PROGRAM BENEFITS

Routine home care No Charge (not subject to the calendar year

medical deductible)

Not Covered 11

Inpatient respite care No Charge (not subject to the calendar year

medical deductible)

Not Covered 11

24-hour continuous home care No Charge (not subject to the calendar year

medical deductible)

Not Covered 11

Short-term inpatient care for pain and symptom management No Charge (not subject to the calendar year

medical deductible)

Not Covered 11

CHIROPRACTIC BENEFITS 7

Chiropractic spinal manipulation Coverage limited to 50 visits per calendar year. 20% 30% ACUPUNCTURE BENEFITS 7

Acupuncture services 20% 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)

20% 30%

SPEECH THERAPY BENEFITS

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

20% 30%

PREGNANCY AND MATERNITY CARE BENEFITS

Prenatal and postnatal physician office visits (may be billed as part of global maternity fee including hospital inpatient delivery services)

10% 30%

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

10% 30%

FAMILY PLANNING BENEFITS

Counseling, consulting, and education (includes injectable and implantable contraceptives for women)

No Charge (not subject to the calendar year

medical deductible)

Not Covered

Intrauterine Device (Insertion and removal of IUD) No Charge (not subject to the calendar year

medical deductible)

30%

Tubal ligation No Charge (not subject to the calendar year

medical deductible)

Not Covered

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

10% Not Covered

DIABETES CARE BENEFITS

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

20% 30%

Diabetes self-management training No Charge (not subject to the calendar year

medical deductible)

30%

HEARING AIDS BENEFITS

Hearing aid instrument and ancillary equipment (plan payment up to $2,000 every 24 months)

No Charge (not subject to the calendar year

medical deductible)

30%

Audioligical exams No Charge (not subject to the calendar year

medical deductible)

30%

CARE OUTSIDE OF CALIFORNIA 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

OPTIONAL BENEFITS Optional dental, vision, infertility, and hearing aid benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately.

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 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.

4 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 $1,500 per day. Members are responsible for 30% of this $1,500 per day, and all charges in excess of $1,500 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.

5 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties (“Designated Counties”), bariatric surgery services are covered only when performed at designated contracting bariatric surgery

facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric

services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a

designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of

Coverage for further details.

6 The maximum allowed charges for non-emergency hospital services received from a non-participating hospital is $1,500 per day. Members are responsible for 30% of this $1,500 per day, and all charges in excess of $1,500 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.

7 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 plan calendar year medical deductible has been met.

8 Services may require prior authorization. When services are prior authorized, members pay the participating provider amount.

9 Mental health and substance use disorder services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) - using MHSA participating and MHSA non-participating providers. Only mental health and substance use disorder services rendered by MHSA participating providers are administered by the MHSA. Mental

health and substance use disorder services rendered by non-MHSA participating providers are administered by Blue Shield.

10 Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for acute medical detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers.

11 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.

Plan designs may be modified to ensure compliance with state and Federal requirements. A44629 (1/17) 20636 DC051017; 053117

blueshieldca.com

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Notice of the Availability of Language Assistance ServicesBlue Shield of California

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 help at no cost, 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 sin cargo, 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。如需免费幫助，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)

MAHALAGA: Nababasa mo ba ang sulat na ito? Kung hindi, maari kaming kumuha ng isang tao upang matulungan ka upang mabasa ito. Maari ka ring makakuha ng sulat na ito na nakasulat sa iyong wika. Para sa libreng tulong, mangyaring tumawag kaagad sa numerong telepono ng Miyembro/Customer Service sa likod ng iyong Blue Shield ID kard, o (866) 346-7198. (Tagalog)

Baa’ ákohwiindzindoo7g7: D77 naaltsoos7sh y77ni[ta’go b77n7ghah? Doo b77n7ghahgóó é7, naaltsoos nich’8’ yiid0o[tah7g77 [a’ nihee hól=. D77 naaltsoos a[d0’ t’11 Din4 k’ehj7 1dooln77[ n7n7zingo b7ighah. Doo b22h 7l7n7g0 sh7k1’ adoowo[ n7n7zing0 nihich’8’ b44sh bee hod7ilnih d00 n1mboo 47 d77 Blue Shield bee n47ho’d7lzin7g7 bine’d44’ bik11’ 47 doodag0 47 (866) 346-7198 j8’ hod77lnih. (Navajo)

중요: 이 서신을 읽을 수 있으세요? 읽으실 수 경우, 도움을 드릴 수 있는 사람이 있습니다. 또한 다른 언어로 작성된 이 서신을 받으실 수도 있습니다. 무료로 도움을 받으시려면 Blue Shield ID 카드 뒷면의 회원/고객 서비스 전화번호 또는 (866) 346-7198로 지금 전환하세요. (Korean)

ԿԱՐԵՎՈՐ Է․ Կարողանում ե՞ք կարդալ այս նամակը։ Եթե ոչ, ապա մենք կօգնենք ձեզ։ Դուք պետք է նաև կարողանաք ստանալ այս նամակը ձեր լեզվով։ Ծառայությունն անվճար է։ Խնդրում ենք անմիջապես զանգահարել Հաճախորդների սպասարկման բաժնի հեռախոսահամարով, որը նշված է ձեր Blue Shield ID քարտի ետևի մասում, կամ (866) 346-7198 համարով։ (Armenian)

ВАЖНО: Не можете прочесть данное письмо? Мы поможем вам, если необходимо. Вы также можете получить это письмо написанное на вашем родном языке. Позвоните в Службу клиентской/членской поддержки прямо сейчас по телефону, указанному сзади идентификационной карты Blue Shield, или по телефону (866) 346-7198, и вам помогут совершенно бесплатно. (Russian)

重要：お客様は、この手紙を読むことができますか？ もし読むことができない場合、弊社が、お客様をサポートする人物を手配いたします。 また、お客様の母国語で書かれた手紙をお送りすることも可能です。 無料のサポートを希望される場合は、Blue Shield IDカードの裏面に記載されている会員/お客様サービスの電話番号、または、(866)346-7198 にお電話をおかけください。(Japanese)

مهم: آیا می توانید این نامه را بخوانید؟ اگر پاسختان منفی است، می توانیم کسی را برای کمک به شما در اختیارتان قرار دهیم. حتی می توانید نسخه مکتوب این نامه را به زبانخودتان دریافت کنید. برای دریافت کمک رایگان، لطفاً بدون فوت وقت از طریق شماره تلفنی که در پشت کارت شناسی تان درج شده است و یا از طریق شماره

(Persian) تلفن با خدمات اعضا/مشتری تماس بگیرید.

ਮਹੱਤਵਪੂਰਨ: ਕੀ ਤੁਸੀਂ ਇਸ ਪੱਤਰ ਨੰੂ ਪੜ੍ਹ ਸਕਦੇ ਹੋ? ਜੇ ਨਹੀਂ ਤਾਂ ਇਸ ਨੰੂ ਪੜ੍ਹਨ ਵਵਚ ਮਦਦ ਲਈ ਅਸੀਂ ਵਕਸ ੇਵਵਅਕਤੀ ਦਾ ਪ੍ਰਬੰਧ ਕਰ ਸਕਦੇ ਹਾਂ। ਤੁਸੀਂ ਇਹ ਪੱਤਰ ਆਪਣੀ ਭਾਸ਼ਾ ਵਵਚ ਵਲਵਿਆ ਹੋਇਆ ਵੀ ਪ੍ਰਾਪਤ ਕਰ ਸਕਦੇ ਹੋ। ਮੁਫ਼ਤ ਵਵਚ ਮਦਦ ਪ੍ਰਾਪਤ ਕਰਨ ਲਈ ਤੁਹਾਡੇ Blue Shield ID ਕਾਰਡ ਦੇ ਵਪੱਛੇ ਵਦੱਤੇ ਮੈਂਬਰ/ਕਸਟਮਰ ਸਰਵਵਸ ਟੈਲੀਫ਼ੋਨ ਨੰਬਰ ਤੇ, ਜਾਂ (866) 346-7198 ਤੇ ਕਾੱਲ ਕਰੋ। (Punjabi)

ប្រការសខំាន៖់ ត�ើអ្នកអាចលខិ�ិតនះបានដែរឬតេ? ត្រើមនិអាចតេ ត�ើងអាចឲ្យតេជួ�អ្នកក្នុងការអានលខិ�ិតនះ។ អ្នកក៏អាចេេួលបានលខិ�ិតនះជាភាសារ្រស់អ្នកផងដែរ។ សបរា្រ់ជនួំ�តោ�ឥ�េិ�ថ ល្ៃ សូមតៅេូរសព័្ទភាលៃ មៗតៅកានត់លខេូរសព័្ទតសវាសរាជកិ/អ�ិ្ជិនដែលរានតៅតលើខ្នង្រណ័្ណ សរាគា ល់ Blue Shield រ្រស់អ្នក ឬតាមរ�ៈតលខ (866) 346-7198។ (Khmer)

المهم :هل تستطيع قراءة هذا الخطاب؟ أن لم تستطع قراءته، يمكننا إحضار شخص ما ليساعدك في قراءته. قد تحتاج أيضاً إلى الحصول على هذا الخطاب مكتوباً بلغتك. للحصول علىالمساعدة بدون تكلفة، يرجى االتصال اآلن على رقم هاتف خدمة العمالء/أحد األعضاء المدون على الجانب الخلفي من بطاقة الهوية أو على الرقم

TSEEM CEEB: Koj pos tuaj yeem nyeem tau tsab ntawv no? Yog hais tias nyeem tsis tau, peb tuaj yeem nrhiav ib tug neeg los pab nyeem nws rau koj. Tej zaum koj kuj yuav tau txais muab tsab ntawv no sau ua koj hom lus. Rau kev pab txhais dawb, thov hu kiag rau tus xov tooj Kev Pab Cuam Tub Koom Xeeb/Tub Lag Luam uas nyob rau sab nraum nrob qaum ntawm koj daim npav Blue Shield ID, los yog hu rau tus xov tooj (866) 346-7198. (Hmong)

ส ำ�คญั: คณุอ�่นจดหม�ยฉบบัน ี ้ไดห้ร อืไม ่ห�กไมไ่ด ้โปรดขอคง�มชว่ยจ�กผ ูอ้�่นได ้คณุอ�จไดร้บัจดหม�ยฉบบัน ีเ้ปน็ภ�ษ�ของคณุ ห�กตอ้งก�รคว�มชว่ยเหลอืโดยไมม่ คี�่ใชจ้�่ย โปรดตดิตอ่ฝ�่ยบร กิ�รลกูค�้/สม�ช กิท�งเบอร ์โทรศพัท์ในบตัรประจำ�ตวั Blue Shield ของคณุ หร อืโทร (866) 346-7198 (Thai)

महतव्परूण्: कय्ा आप इस पतर् को पढ़ सकत ेह ै ?ं यदि नह ी ,ं तो हम इस ेपढ़न ेम े ंआपक ी मदद क ेलि ए कि स ी वय्कत्ि का पर्ब ंध कर सकत ेह ै।ं आप इस पतर् को अपन ी भाषा म े ंभ ी पर्ापत् कर सकत ेह ै।ं नि :शलुक् मदद पर्ापत् करन ेक ेलि ए अपन ेBlue Shield ID कारड् क ेप ीछ ेदि ए गय े म े ंबर/कसट्मर सरव्ि स ट ेल ीफोन न ंबर, या (866) 346-7198 पर कॉल कर े।ं (Hindi)

Blue Shield(866) 346-7198

Blue Shield.(866) 346-7198(Arabic)

Notice Informing Individuals about Nondiscrimination and

Accessibility Requirements

Discrimination is against the law

Blue Shield of California complies with applicable federal civil rights laws and does not discriminate on the

basis of race, color, national origin, age, disability or sex. Blue Shield of California does not exclude people or

treat them differently because of race, color, national origin, age, disability or sex.

Blue Shield of California:

• Provides aids and services at no cost to people with disabilities to communicate effectively with us such

as:

- Qualified sign language interpreters

- Written information in other formats (including large print, audio, accessible electronic formats and

other formats)

• Provides language services at no cost to people whose primary language is not English such as:

- Qualified interpreters

- Information written in other languages

If you need these services, contact the Blue Shield of California Civil Rights Coordinator.

If you believe that Blue Shield of California has failed to provide these services or discriminated in another

way on the basis of race, color, national origin, age, disability or sex, you can file a grievance with:

Blue Shield of California Civil Rights

Coordinator

P.O. Box 629007

El Dorado Hills, CA 95762-9007

Phone: (844) 831-4133 (TTY: 711) Fax: (916) 350-7405 Email: BlueShieldCivilRightsCoordinator@blueshieldca.com

You can file a grievance in person or by mail, fax or email. If you need help filing a grievance, our Civil

Rights Coordinator is available to help you.

You can also file a civil rights complaint with the U.S. Department of Health and Human Services,

Office for Civil Rights electronically through the Office for Civil Rights Complaint Portal, available at

https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by mail or phone at:

U.S. Department of Health and Human Services

200 Independence Avenue SW.

Room 509F, HHH Building Washington,

DC 20201

(800) 368-1019; TTY: (800) 537-7697

Complaint forms are available at www.hhs.gov/ocr/office/file/index.html.

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mailto:BlueShieldCivilRightsCoordinator@blueshieldca.comhttp://www.hhs.gov/ocr/office/file/index.html

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