This is a Self Funded PPO Plan with coverage worldwide for medically necessary treatments.

Choose any physician or hospital. Reduced charges are available from the Preferred Provider hospital and physician networks that have a contract with the Plan. Your out-of-pocket expenses will be higher when you use a provider or facility that is not a Preferred Provider.

The Plan contracts with the Blue Shield Shared Advantage Program for is Preferred Provider Organization (PPO) and medical case management services.

• Using provider from the PPO network saves both you and the Plan money. To find a PPO provider, access www.blueshieldca.com
• Prior Authorization/Pre-Admission Review: Before any non-emergency hospitalization, you should call 800-343-1691 to determine whether a procedure or treatment program is covered, or if an alternative service is recommended.
• Life Referrals 24/7 (Employee Assistance Program) This program allows members to access a 24/7 help line (800-985-2405) to speak with a mental health counselor, life coach, or even financial advisors.
• Effective August 1, 2011, PPO participants will have access to Blue Shield’s disease management and personalized case management services. Members who qualify for these programs are identified from medical and pharmacy claims, as well as referrals from physicians. All information is kept confidential. These programs are member friendly and not intended as a substitute for patient/provder communications. Participation is voluntary and members may opt out at any time.

The complex case management program provides a range of specialized services for indviduals with multiple conditions, advanced date cancer and acute circulatory or digestive conditions, as well as support for individuals and their families who face end of life hospice care.

The disease management program is designed to help members manage their chronic conditions, improve their qualify of life and minimize the cost of health care. Personalized at home support services are available for conditions including asthma, diabetes, chronic obstructive pulmonary disease, congestive heart failure and coronary artery disease. The services may include educational materials, a link to the website and, in some cases, phone calls from a registered nurse who can provide additional support and respond to questions.

2011: $750,000
2012: $1,500,000
2013: $2,000,000
2014: None

Lifetime Maximum: None.

$100 per person per calendar year, or
$200 per family per calendar year

After satisfying the deductible, benefits are paid at 80% of the PPO contract rate for services provided by a PPO Provider and 60% of usual and customary charges for services provided by a non-PPO provider. For each covered person, there is a $1,500 out-of-pocket maximum per calendar year. After a person has met the out-of-pocket maximum, covered charges for a PPO Provider will be paid at 100% of the PPO contract rate and 80% of the usual and customary charges for services provided by a non-PPO Provider.

The benefits apply to the following Covered Services for reasonable and customary charges for services, treatment, and supplies for the care and treatment of an illness or injury:

1. Hospital Room and Board and Miscellaneous charges
2. Surgery
3. Anesthesia
4. Physician or other Licensed or Certified Health Care Provider visits
5. Outpatient lab & x-rays
6. Annual physical and immunization inoculations (up to $300 calendar year maximum)
7. Ambulance services to move patient from place of injury or illness to nearest hospital equipped to provide necessary care
8. Mother's outpatient maternity related care*
9. Mother's and newborn baby's in patient hospital care for up to 48 hours following normal delivery and 96 hours following caesarian section.*

*applies to members/spouses/domestic partners only.

Other Covered Benefits include:

Benefits for services provided by contracting PPO Providers will be reimbursed at 100% of the PPO Contract Rate; benefits for services provided by non-Contracting PPO Providers are reimbursed at 60% of usual and customary charges once the annual deductible of $100 per person/$200 per family is satisfied, and at 80% of usual and customary charges after reaching the $1,500 per person "out of pocket" maximum.

100% reimbursement of reasonable and customary charges for:
Fecal occult blood test
Flexible Sigmoidoscopy
Colonoscopy
Pap smears and Pelvic Exams
Prostate Cancer Screenings
Mammogram Screenings (some age based limitations)

These services will each be limited to a maximum of 30 visits per calendar year effective January 1, 2009.

See the Prescription tab for information regarding the Self Fund PPO Plan prescription drug program administered by Caremark.

In general, the Plan does not cover charges for treatment that is not generally accepted by the medical profession or is considered experimental, under investigation, or limited to research. However, alternative treatment for physical symptoms that are suspected of being caused or related to autism are covered as follows.

Coverage limited to $3,000 per Calendar Year is available for alternative treatment for a condition suspected of playing a role in the expression of symptoms of autism, including:

• vitamin supplementation therapy;
• oral secretin therapy;
• chelation;
• hyperbaric oxygen therapy;
• cranio-sacral therapy;
• fibroblast growth factor therapy;
• live cell and stem cell therapy;
• anti-fungal therapy;
• antibiotic therapy; and
• naltextrone therapy .

Charges incurred as a result of a work related injury or illness or for which a third party tortfeasor is responsible are not covered under the Plan. However, benefits may be advanced from the Plan pending determination by way of court or administrative determination of third party liability, or by way of settlement, whether or not the third party is responsible for payment of medical expenses. Eligible members may qualify for the advance upon completion of the xxxx form.

The Self Funded PPO Plan is a "grandfathered health plan" under the ACA. As permitted by the ACA, a grandfathered health plan can preserve certain basic health coverage that was already in effect when that law was enacted. Although being a grandfathered health plan means that the Plan is not required to include certain consumer protections of the ACA that apply to other plans (for example, the requirement for the provision of preventive health services without any cost sharing), the Plan must comply with certain other consumer protections in the ACA (for example the elimination of lifetime limits on benefits and extension of dependent coverage to adult children to age 26). In addition, the Plan provides health coverage benefits far beyond the "basic" level of benefits and has long maintained many consumer protections now required under the ACA (for example, it provides many preventive screening procedures at 100% of usual and customary charges, bans rescissions of coverage due to a member's health condition, exclusions for pre-existing conditions for children and adults, and "waiting periods" after a member attains initial coverage based on hours of work). Questions regarding which protections apply and which do not apply to a grandfathered health plan and what might cause a plan to change from grandfathered health plan status can be directed to the contract plan administrator, EISB, at (415) 263-3670. You may also contact the Employee Benefits Security Administration, U.S. Department of Labor at 1 (866) 444-3272 or www.dol.gov/ebsa/healthreform. This website has a table summarizing which protections do and do not apply to grandfathered health plans.