Table of Contents

Introduction ........................................................................................... 1

Your Medical Plan Options ....................................................................................................................................................... 1

Designating a Primary Care Physician (PCP) .................................................................................................................... 2

Waive Coverage Option ............................................................................................................................................................. 3

Medical Coverage Requirements ................................................................................................................................................ 3

Newborns' and Mothers' Health Protection Act .................................................................................................................. 3

Reconstructive Surgery Following A Mastectomy ............................................................................................................... 3

Your Medical Plan Options At-A-Glance ......................................... 4

When Coverage Begins .......................................................................... 8

For Yourself ............................................................................................................................................................................... 8

If You're Absent From Work ............................................................................................................................................... 8

For Your Dependents ................................................................................................................................................................ 8

About The HMOs ....................................................................................... 9

Blue Cross CaliforniaCare ......................................................................................................................................................... 9

Aetna, CIGNA, Health Net, Kaiser Permanente and Maxicare ......................................................................................... 10

About The Blue Cross Plus Point-Of-Service (Pos) Plan ......... 10

How the Plan Works ................................................................................................................................................................ 10

Receiving Care in the POS Plan ............................................................................................................................................... 11

Annual Deductible ................................................................................................................................................................... 12

Copays ..................................................................................................................................................................................... 12

Coinsurance .............................................................................................................................................................................. 13

Usual and Customary (U&C) Charges .................................................................................................................................... 13

Taking Advantage of the Tier I and Tier II Options ................................................................................................................ 14

Out-of-Pocket Maximum ......................................................................................................................................................... 15

Utilization Review (UR) Penalties........................................................................................................................................... 16

Lifetime Maximum ................................................................................................................................................................... 16

Tier I and Tier II ............................................................................................................................................................... 16

Tier III ............................................................................................................................................................................... 16

Seeing Specialists in Tier I ....................................................................................................................................................... 17

Seeing Specialists in Tiers II and III ........................................................................................................................................ 18

Emergency and Urgent Care Services Within Your Service Area ............................................................................................. 18

Traveling Outside the Service Area .......................................................................................................................................... 20

What Is Covered ...................................................................................................................................................................... 21

What Is Covered Under Tiers I, II and III ........................................................................................................................ 21

What Is Covered Under Tier I Only .................................................................................................................................. 26

What Is Covered Under Tiers II and III Only .................................................................................................................. 27

What Is Not Covered ............................................................................................................................................................... 28

What Is Not Covered Under Tiers I, II and III ................................................................................................................. 28

What Is Not Covered Under Tier I .................................................................................................................................... 31

What Is Not Covered Under Tiers II and III ..................................................................................................................... 31

Utilization Review ................................................................................................................................................................... 32

If You Have an Emergency ................................................................................................................................................ 33

Authorization Referrals ..................................................................................................................................................... 33

Chiropractic Benefits ............................................................................................................................................................... 34

About The Safety Net Plan ................................................................ 35

How the Plan Works ................................................................................................................................................................ 35

Annual Deductible ................................................................................................................................................................... 36

Copays ..................................................................................................................................................................................... 36

Coinsurance .............................................................................................................................................................................. 36

How Coinsurance Works ................................................................................................................................................. 36

Usual and Customary (U&C) Charges .................................................................................................................................... 37

Taking Advantage of Network Providers ................................................................................................................................ 37

Out-of-Pocket Maximum ......................................................................................................................................................... 38

Lifetime Maximum ................................................................................................................................................................... 38

Emergency and Urgent Care Services ....................................................................................................................................... 38

What Is Covered ...................................................................................................................................................................... 39

What Is Not Covered ............................................................................................................................................................... 44

Utilization Review ................................................................................................................................................................... 47

What You Must Do ............................................................................................................................................................ 48

If You Have An Emergency ................................................................................................................................................ 48

Chiropractic Benefits ............................................................................................................................................................... 48

About The Out-Of-Area Plan .............................................................. 49

How the Plan Works ................................................................................................................................................................ 49

Annual Deductible ................................................................................................................................................................... 49

Copays ..................................................................................................................................................................................... 50

Coinsurance .............................................................................................................................................................................. 50

How Coinsurance Works ................................................................................................................................................. 50

Usual and Customary (U&C) Charges .................................................................................................................................... 51

Out-of-Pocket Maximum ......................................................................................................................................................... 51

Lifetime Maximum ................................................................................................................................................................... 51

Emergency and Urgent Care Services ....................................................................................................................................... 52

What Is Covered ...................................................................................................................................................................... 52

What Is Not Covered ............................................................................................................................................................... 57

Utilization Review ................................................................................................................................................................... 60

Utilization Review (UR) Penalties .......................................................................................................................................... 61

What You Must Do ............................................................................................................................................................ 61

If You Have An Emergency ................................................................................................................................................ 61

Authorization Referrals ..................................................................................................................................................... 62

Chiropractic Benefits ............................................................................................................................................................... 62

Prescription Drug Program ............................................................. 63

Retail Program .......................................................................................................................................................................... 63

Mail-Order Drug Program ........................................................................................................................................................ 64

What Is Covered ..................................................................................................................................................................... 65

What Is Not Covered ............................................................................................................................................................... 65

Drug Preauthorization .............................................................................................................................................................. 66

Mental Health And Substance Abuse Coverage ........................ 67

The Employee Assistance Program (EAP) .............................................................................................................................. 67

Benefit Amount ................................................................................................................................................................... 67

How to Access Care .......................................................................................................................................................... 67

Mental Health Program ............................................................................................................................................................ 68

How to Access Care .......................................................................................................................................................... 68

What Is Covered ................................................................................................................................................................ 69

What Is Not Covered ......................................................................................................................................................... 70

Coordination Of Benefits .................................................................. 73

How Is It Determined Which Plan Pays First? ....................................................................................................................... 73

Dependent Expenses .......................................................................................................................................................... 74

Coordination with HMOs .................................................................................................................................................. 74

Coordination with Medicare .............................................................................................................................................. 75

Changes In Your Employment Status ............................................ 76

When Coverage Ends ........................................................................... 77

For Yourself ............................................................................................................................................................................ 77

For Your Dependents .............................................................................................................................................................. 77

Continuing Your Coverage ....................................................................................................................................................... 77

Coverage Certification .............................................................................................................................................................. 77

Late Enrollee-If You Waive Your Medical Coverage (California Only) .................................................................................. 78

Submitting Claims ................................................................................ 79

Recovery of Overpayment ...................................................................................................................................................... 79

Third Party Reimbursements ................................................................................................................................................... 79

Terms You Should Know ..................................................................... 81

Introduction

Comprehensive, affordable healthcare is important not only in keeping you healthy but also in making sure you and your family are secure and protected. The Company offers several medical plans so that you can choose a coverage option best suited to your needs. The plans differ in terms of cost, how you see a doctor and the amount of flexibility you have when using the plan.

Your Medical Plan Options

The Company offers six Health Maintenance Organizations (HMOs), Aetna, Blue Cross CaliforniaCare, CIGNA, Health Net, Kaiser Permanente and Maxicare, a Blue Cross Plus Point-of-Service (POS) plan and two Indemnity plans, Safety Net and an Out-of-Area plan.

The HMOs emphasize preventive care and offer overall lower out-of-pocket costs when you receive services. With the HMOs, (except Kaiser) all of your care will be provided or coordinated by your primary care physician (PCP), a doctor you select from the HMO network when you join the plan.

The Blue Cross Plus POS plan offers you the flexibility to choose how you get care at the time you need medical services. You can receive care through your primary care provider, from a Prudent Buyer doctor or hospital, or from a doctor or hospital that is not in either network. The three options offer different levels of freedom of choice and out-of-pocket cost. You can choose the mix of choice and cost that’s right for you.

The Out-of-Area plan is for employees who live outside the HMO and POS service areas. You can use any provider, but you will pay less if you choose a participating network provider who is a member of the local Blue Cross network. Depending on where you live, there may not be participating network providers in your area.

The Safety Net plan is a “catastrophic plan” and is the least costly form of protection against major health care expenses. Once you meet your deductible (usually higher than typical indemnity plans), the plan pays a large percentage of covered expenses.

Designating a Primary Care Physician (PCP)

Except in Kaiser, Safety Net and the Out-of-Area plan, you need to designate a PCP when you enroll in a medical plan. PCPs can associate with a medical group, or act as individual practitioners but associate with other individual practitioners to facilitate administrative services, such as billing.

If you select a PCP who is part of an individual practice association (IPA), you may need to go to a different facility for referrals and ancillary services such as X-rays and laboratory tests.

If you select a primary medical group (PMG), most services are located in the same facility as your doctor. An additional feature of a PMG is that if your doctor is not available, you can see another PCP within the medical group with no reduction in benefits.

An “At-A-Glance” chart of your medical options begins on page 4, followed by detailed information about the plans.

Waive Coverage Option

If you do not want medical coverage, you may choose to waive company medical coverage when you are selecting your benefits if you are a newly eligible employee, or during the annual open enrollment period. You should only do this if you have access to other medical coverage, such as through a spouse’s plan.

Medical Coverage Requirements

Regardless of the medical plan you have selected, certain coverage levels are required under federal law.

Newborns’ and Mothers’ Health Protection Act

Under the Newborns’ and Mothers’ Health Protection Act of 1996 (NMHPA), group health plans and health insurers generally may not, under federal law, restrict benefits for any hospital length of stay in connection with childbirth for the mother or newborn child to less than 48 hours following a vaginal delivery or 96 hours following cesarean section. An earlier release is permitted if both the mother and her doctor agree to an earlier release.

Reconstructive Surgery Following A Mastectomy

Following a mastectomy, medical plans must cover reconstruction of the breast on which the mastectomy was performed, surgery and reconstruction of the other breast to produce a symmetrical appearance, treatment of any physical complications and any necessary prosthesis on the same basis as other covered services.

Your Medical Plan Options At-A-Glance

	HEALTH MAINTENANCE ORGANIZATIONS (HMOs)
	Aetna	Blue Cross CaliforniaCare	CIGNA
Who Provides Care	All care coordinated by your primary care physician	All care coordinated by your primary care physician	All care coordinated by your primary care physician
Annual Deductible	None	None	None
Annual Out-of-Pocket Maximum (including deductible)	$1,500/person; $3,000/family	$2,000/person	$1,000/person; $3,000/family
Network Area	Based on home ZIP code	Based on home or work ZIP code	Based on home ZIP code
Benefits for Most Covered Services	Plan pays 100% of covered expenses. There is no deductible, but copays are required in many cases	Plan pays 100% of covered expenses. There is no deductible, but copays are required in many cases	Plan pays 100% of covered expenses. There is no deductible, but copays are required in many cases
Lifetime Maximum	Unlimited	Unlimited	Unlimited
Physician Office Visits and Home Visits	You pay $10 copay	You pay $10 copay	You pay $10 copay for office visit. Plan pays 100% of covered expenses for home health care visits
Routine Physical Exams and Well Baby Care	Included in $10 office visit copay	Included in $10 office visit copay	You pay $10 copay
Inpatient Hospital Services	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses
Outpatient Testing (Laboratory Tests, X-Rays, Pathology)	You pay $10 copay	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses
Surgeons, Assistant Surgeons, Anesthesiologists	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses
Emergency Room Services	You pay $35 copay (waived if admitted). Non-emergency care is not covered	You pay $25 copay (waived if admitted). Non-emergency care is not covered	You pay $50 copay (waived if admitted). You pay $50 copay for non-emergency care when authorized by your PCP
Urgent Care	You pay $35 copay when certified by PCP	You pay $10 copay if associated with PMG or authorized by PCP	You pay $15 copay for after hours visit at your medical group; otherwise, treated as emergency
Rental of Medical Equipment	Plan pays 100% of covered expenses for durable medical equipment if authorized	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses
Chiropractic Care	Not covered	Not covered	Not covered
Specified Immunizations	Included in $10 office visit copay	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses
Prescription Drugs	You pay $5 copay generic, $10 brand** or $25 non-formulary for 30-day supply at participating pharmacy or 90-day supply through mail order	You pay $5 copay generic/$7 copay brand** for 30-day supply at participating pharmacy. You pay $5 generic/$12 brand** for a 90-day supply through mail order	You pay $5 copay generic or brand** for 30-day supply at participating pharmacy
Mental Health and Substance Abuse	Benefits for inpatient and outpatient treatment for mental/nervous conditions and substance abuse vary greatly between HMOs. Refer to your HMO booklet for details. If you are covered by an HMO you are eligible for detoxification treatment through the Employee Assistance Plan. This detoxification treatment is subject to preauthorization by Holman Counseling Centers, Inc., and is not available to dependents. Blue Cross CaliforniaCare HMO members are eligible for the same mental health/substance abuse coverage as members of Blue Cross Plus.

Maternity care is covered the same as any other condition.
** When generic not available.

	HEALTH MAINTENANCE ORGANIZATIONS (HMOs)
	Health Net	Kaiser Permanente	Maxicare
Who Provides Care	All care coordinated by your primary care physician	You must use Kaiser physicians and hospitals	All care coordinated by your primary care physician
Annual Deductible	None	None	None
Annual Out-of-Pocket Maximum (including deductible)	$1,500/person; $4,500/family	$1,500/person; $3,000/family	$1,000/person; $2,000/family
Network Area	Based on home ZIP code	Based on home ZIP code	Based on home ZIP code
Benefits for Most Covered Services	Plan pays 100% of covered expenses. There is no deductible, but copays are required in many cases	Plan pays 100% of covered expenses. There is no deductible, but copays are required in many cases	Plan pays 100% of covered expenses. There is no deductible, but copays are required in many cases
Lifetime Maximum	Unlimited	Unlimited	Unlimited
Physician Office Visits and Home Visits	You pay $10 copay for office visit and $20 copay for home visit	You pay $10 copay for office visit. No charge for scheduled prenatal or for home visits	You pay $10 copay
Routine Physical Exams and Well Baby Care	You pay $10 copay for periodic health evaluation. No charge for scheduled Well Baby care up to 24 months	You pay $10 copay. No charge for scheduled Well Baby care up to 24 months	You pay $10 copay
Inpatient Hospital Services	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses
Outpatient Testing (Laboratory Tests, X-Rays, Pathology)	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses	Plan pays 100% of covered expenses after copay
Surgeons, Assistant Surgeons, Anesthesiologists