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Home My WebLink AboutAgreement A-23-656 Participation Agreement with SJVIA.pdf Agreement No. 23-656 SJVIA PARTICIPATION AGREEMENT THIS AGREEMENT ("Agreement") is made and entered into this 12th day of December, 2023, by and between COUNTY OF FRESNO, a political subdivision of the State of California, hereinafter referred to as "COUNTY OF FRESNO," and the SAN JOAQUIN VALLEY INSURANCE AUTHORITY, a joint powers agency, hereinafter referred to as "SJVIA." WITNESSETH: WHEREAS, the purpose of the SJVIA is to develop and provide various health insurance programs for health, pharmacy, vision, dental, mental health and life insurance, including related administrative services for such programs to be provided by the insurance provider(s) and the SJVIA and its agents and consultants (collectively, "Various Benefits"), for the benefit of participating entities; and WHEREAS, the COUNTY OF FRESNO wishes to participate in the SJVIA Various Benefits for the purpose of purchasing health insurance programs, and/or other benefits in a cost-effective manner for each of the COUNTY OF FRESNO's participating employees; and WHEREAS, the COUNTY OF FRESNO elects to participate in the selected SJVIA health insurance programs as referenced in Exhibit "A" (collectively, "SELECTED PROGRAMS"); and WHEREAS, a true and correct copy of a summary of applicable SJVIA health insurance programs is attached hereto and incorporated herein by reference as Exhibit "A"; and WHEREAS, the SJVIA represents that it will contract with Insurance Providers which will provide its Various Benefits under the terms and conditions of a written contract, including amendments thereof, if any, between the SJVIA and the Insurance Provider(the"Insurance Contract") for each of the COUNTY OF FRESNO's participating employees; and WHEREAS, the SJVIA represents that the rates for the Various Benefits under the SELECTED PROGRAMS to be provided to COUNTY OF FRESNO under the Insurance Contract and by the SJVIA, including the costs of its agents and consultants, are set forth in Exhibit "B" which is attached hereto and incorporated herein by reference; and WHEREAS, the COUNTY OF FRESNO and the SJVIA now desire to enter into this Agreement to secure the COUNTY OF FRESNO's commitment to remit premium payments to the SJVIA for the Various Benefits to be provided under the Insurance Contract, and the COUNTY OF FRESNO's portion of the costs of the SJVIA's agents and consultants, as provided herein. NOW THEREFORE, in consideration of their mutual promises, covenants and conditions, the parties agree as follows: 1. COUNTY OF FRESNO's OBLIGATIONS: The COUNTY OF FRESNO acknowledges that this agreement requires a commitment to participate in SJVIA Various Benefits effective December 11, 2023 through December 31, 2024, subject to the terms and conditions of this Agreement. Within ten (10) business days of the date that SJVIA is required under the Insurance Contract to pay any insurance premium and/or similar charge to the Insurance Provider, the COUNTY OF FRESNO shall remit to SJVIA the amount necessary to pay the required premium payment based on the intervals of such payments under the Insurance Contract. - 1 - The COUNTY OF FRESNO may also participate in SELECTED PROGRAMS as referenced in Exhibit "A" and shall comply with all applicable terms and provisions of the Insurance Contract and this Agreement, effective December 11, 2023. The attached rates in Exhibit "B" reference only the SELECTED PROGRAMS the COUNTY OF FRESNO is electing. Exhibit "B" also references the effective term such rates apply to the COUNTY OF FRESNO which are effective December 11, 2023 through December 31, 2024. The COUNTY OF FRESNO agrees that it may only elect to participate in additional health insurance programs, or elect to make changes to the SELECTED PROGRAMS, through subsequent amendment to this agreement or separate agreement. Subsequent renewals are based on the SJVIA underwriting guidelines. 2. SJVIA'S OBLIGATIONS: The SJVIA shall timely approve and execute all Insurance Contracts. Following execution of the Insurance Contracts, (i) SJVIA shall make available the fully- executed copy of the Insurance Contract to COUNTY OF FRESNO, (ii) SJVIA shall enforce SJVIA's rights under the Insurance Contract for the benefit of COUNTY OF FRESNO, (iii) SJVIA shall perform SJVIA's obligations under the terms and conditions of the Insurance Contracts, including making timely payment of premium payments, and/or any similar charges, necessary to keep the Insurance Contracts in full force and effect, and (iv) provide COUNTY OF FRESNO with the then-current total amounts required to be paid by COUNTY OF FRESNO each eligibility period in order for SJVIA to pay any insurance premium and/or similar charge to the Insurance Provider, including the costs of its agents and consultants, allocable to the COUNTY OF FRESNO. The SJVIA represents and covenants to the COUNTY of FRESNO that the SJVIA shall use actuarially-based underwriting standards with respect to all SJVIA operations. 3. MODIFICATION: Any matters of this Agreement may be modified from time to time but only by the written consent of all the parties hereto without, in any way, affecting the remainder hereof. Any proposed modifications to the rates referenced in Exhibit "B" will need approval by the Board of Directors of the SJVIA and the Board of Supervisors of the COUNTY OF FRESNO. 4. NON-ASSIGNMENT: Neither party hereto shall assign, transfer, or subcontract this Agreement nor their rights or duties under this Agreement without the prior written consent of the other party hereto. 5. AUDITS AND INSPECTIONS: The SJVIA shall at any time during usual SJVIA business hours, upon request by the COUNTY OF FRESNO, and as often as the COUNTY OF FRESNO may deem necessary, make available to the COUNTY OF FRESNO for examination all SJVIA records and data for inspection, examination, and audit by the COUNTY OF FRESNO with respect to the matters covered by this Agreement. SJVIA shall be subject to the examination and audit of the State Auditor General for a period of three (3) years after final payment under contract (Government Code section 8546.7). 6. NOTICES: The persons having authority to give and receive notices under this Agreement and their addresses include the following: COUNTY OF FRESNO SJVIA Hollis Magill Lupe Garza Director of Human Resources SJVIA Manager 2220 Tulare St., 161" Floor 2500 West Burrel Fresno, CA 93721 Visalia, CA 93291 hmagill(a_fresnocountyca.gov Iugarza(aD_tularecounty.ca.gov 2 - Either party may change the information in this section 6 by giving notice as provided in this section 6. Each notice between the COUNTY OF FRESNO and the SJVIA provided for or permitted under this Agreement must be in writing, state that it is a notice provided under this Agreement, and be delivered either by personal service, by first-class United States mail, by an overnight commercial courier service, by telephonic facsimile transmission, or by Portable Document Format (PDF) document attached to an email, or by email from an authorized email account. a. A notice delivered by personal service is effective upon service to the recipient. b. A notice delivered by first-class United States mail is effective three sender business days after deposit in the United States mail, postage prepaid, addressed to the recipient. c. A notice delivered by an overnight commercial courier service is effective one sender business day after deposit with the overnight commercial courier service, delivery fees prepaid, with delivery instructions given for next day delivery, addressed to the recipient. d. A notice delivered by telephonic facsimile transmission or by PDF document attached to an email, or authorized email account, is effective when transmission to the recipient is completed (but, if such transmission is completed outside of the sender's business hours, then such delivery is deemed to be effective at the next beginning of a sender's business day), provided that the sender maintains a machine record of the completed transmission. For all claims arising from or related to this Agreement, nothing in this Agreement establishes, waives, or modifies any claims presentation requirements or procedures provided by law, including the Government Claims Act (Division 3.6 of Title 1 of the Government Code, beginning with section 810). 7. GOVERNING LAW: The parties agree that for the purposes of venue, performance under this Agreement is to be in Fresno County, California. The rights and obligations of the parties and all interpretation and performance of this Agreement shall be governed in all respects by the laws of the State of California. 8. TERM: This Agreement shall become effective beginning at 12:01 a.m. on December 11, 2023 and shall terminate on December 31, 2024. 9. TERMINATION: a. The terms of this Agreement, and the health insurance programs, administrative services, and/or SJVIA staff costs to be provided hereunder, are contingent on the approval of funds by the COUNTY OF FRESNO. Should sufficient funds not be allocated, the services provided may be modified, or this Agreement terminated at any time by COUNTY OF FRESNO giving SJVIA at least one hundred twenty (120) days advance written notice. b. Notwithstanding any other provision of this Article, if the COUNTY OF FRESNO fails to make in full any payment when due pursuant to Article 1, the SJVIA shall have the right, in its sole discretion, to terminate this Agreement, upon at least ten (10) days written notice, effective at the expiration of the last period for which full premium payment was made. Notwithstanding such termination or suspension, the SJVIA, in its sole discretion, may accept late payment or delinquent - 3 - amounts and, upon acceptance, this Agreement may be reinstated retroactively to the last date for which full premium payment was made. Any such acceptance of a delinquent payment by the SJVIA shall not be deemed a waiver of this provision for termination of this Agreement in the event of any future failure of the COUNTY OF FRESNO to make timely payments of any amounts due under this Agreement. 10. INDEPENDENT RELATIONSHIP: Nothing in this Agreement shall create, or be deemed to create, any relationship of principal-agent, master-servant, employer-employee, partnership,joint venture, or association between SJVIA and COUNTY OF FRESNO. The relationship between SJVIA and COUNTY OF FRESNO under this Agreement is that of independent contractors, with each such party at all times acting in an independent capacity from the other. 11. SEVERABILITY: In the event any provisions of this Agreement are held by a court of competent jurisdiction to be invalid, void, or unenforceable, the parties will use their best efforts to meet and confer to determine how to mutually amend such provisions with valid and enforceable provisions, and the remaining provisions of this Agreement will nevertheless continue in full force and effect without being impaired or invalidated in any way. 12. DISPUTE RESOLUTION: Any controversy or dispute between the parties arising out of this agreement shall be submitted to mediation. The mediator will be selected by mutual agreement. If the matter cannot be resolved through mediation or if the parties cannot agree upon a mediator the matter shall be submitted to arbitration and such arbitration shall comply with and be governed by the provisions of the California Arbitration Act, of the California Code of Civil Procedure. 13. NO THIRD-PARTY BENEFICIARIES: This Agreement does not and is not intended to create any rights or obligations for any person or entity except for SJVIA and COUNTY OF FRESNO. 14. ENTIRE AGREEMENT: This Agreement constitutes the entire agreement between the SJVIA and COUNTY OF FRESNO with respect to the subject matter hereof and supersedes all previous agreement negotiations, proposals, commitments, writings, advertisements, publications, and understandings of any nature whatsoever unless expressly included in this Agreement. 15. COUNTERPARTS: This Agreement may be executed in one or more original counterparts, all of which together will constitute one and the same agreement. (Go to next page for signatures) 4 - SJVIA PARTICIPATION AGREEMENT BETWEEN COUNTY OF FRESNO AND THE SAN JOAQUIN VALLEY INSURANCE AUTHORITY SAN JOAQUIN LEY INSURANCE COUNTY OF FRESNO: AUTHORITY: By: By._ Steve Brandau Sai Qui ero SJVIA Board President Chaifman tithe Board of Supervisors of the County of Fresno Date: I Z D�f'Z3 Date: _ l� l R -,2 0a3 REVIEWED& RECOMMENDED ATTEST: FOR APPROVAL Bernice E. Seidel Clerk of the Board of Supervisors County of Fresno, State of California By: � - 3A— By:_ Lupe Garza Deputy SJVIA Manager 5 - BOARD OF DIRECTORS STEVE BRANDAU NATHAN MAGSIG VIA BUDDY MENDES San Joaquin Valley LARRYMICARI BRIAN PACHECO Insurance Authority AMYSHUKLIAN PETE VANDER POEL Exhibit A County of Fresno Plan Year 2024 Benefit Summaries • Anthem Blue Cross EPO 0 • Anthem Blue Cross EPO 500 • Anthem Blue Cross EPO 1000 • Anthem Blue Cross PPO 250 • Anthem Blue Cross HDHP PPO 1500 (Retirees) • Anthem Blue Cross HSA PPO 3000 (Bi-Weekly) • Anthem Blue Cross HDHP 3000 (Special Districts) • EmpiRx Health Prescription Benefit EPO-PPO • EmpiRx Health Prescription Benefit HD 1500 (Retirees) • EmpiRx Health Prescription Benefit HD 3000 • Kaiser Permanente HMO • Kaiser Permanente Chiro • Kaiser Permanente DHMO • Delta Dental PPO • Delta Dental DHMO • VSP Vision Benefit Your summary . benefits At em 0 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA)- County of Fresno: Custom EPO 0 Your Network: EPO Care-OnlyFVisits with Virtual . . mobile Primary Care, and medical services for urgentlacute care $15 copay per visit Mental Health &Substance Use Disorder Services $15 copay per visit Specialist care $15 copay per visit Covered Medical Benefits Cost if you use an In-Network . - Overall Deductible $0 person Overall Out-of-Pocket Limit $1,000 person / $2,000 family To get benefits under this Plan, you must use In-Network Providers. Services from Non-Network Providers are not covered, except for Emergency Care, Authorized Services, or when required by law. Please be sure to contact us if you are not sure if we have approved an Authorized Service. The family out-of-pocket limit is embedded, meaning each covered person is capped at his or her per person out-of-pocket limit; in addition, cost shares for all covered family members apply to the family out-of-pocket limit, yet no one member will pay more than the per person out-of-pocket limit. All medical and deductibles, copayments and coinsurance apply to the out-of-pocket limit. Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder $15 copay per visit Services virtual and office Specialist Care virtual and office $15 copay per visit Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) No charge Retail Health Clinic for routine care and treatment of common illnesses; $15 copay per visit usually found in major pharmacies or retail stores. Manipulation Therapy $10 copay per visit CA/1.G/Custom EPO 0/6LW7/01-01-2024 Page 1 of 9 i MedicalCovered . - Coverage is limited to 40 visits per benefit period. Acupuncture $15 copay per visit Other Services in an Office Allergy Testing No charge Prescription Drugs Dispensed in the office No charge Maximum of$250 member cost share per drug. Surgery No charge Preventive care I screenings 1 immunizations No charge Preventive Care for Chronic Conditions per IRS guidelines No charge Diagnostic Services Lab Office No charge Freestanding Lab No charge Outpatient Hospital No charge X-Ray Office No charge Freestanding Radiology Center No charge Outpatient Hospital No charge Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office No charge Freestanding Radiology Center No charge Outpatient Hospital No charge i Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply $15 copay per visit depending on the care provided. Page 2of9 i MedicalCovered . - Emergency Room Facility Services In-Network and Non-Network Providers: Your copay will be waived if admitted. $100 copay per visit Emergency Room Doctor and Other Services In-Network and Non-Network Providers: No charge Ambulance In-Network and Non-Network Providers: Authorized Non-Network non-emergency ambulance services are limited No charge to an Anthem maximum payment of$50,000 per trip. Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees No charge Doctor Services No charge k I Outpatient Surgery Facility Fees Hospital No charge Ambulatory Surgical Center No charge Physician and other services including surgeon fees Hospital No charge Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) Facility Fees No charge Physician and other services including surgeon fees No charge Home Health Care $15 copay per visit Coverage is limited to 100 visits per benefit period. Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical therapy, occupational therapy and speech therapy is limited to 60 days combined per benefit period. Office $15 copay per visit Outpatient Hospital No charge Page 3of9 i MedicalCovered . - Pulmonary rehabilitation Office $15 copay per visit Outpatient Hospital No charge Cardiac rehabilitation Office $15 copay per visit Outpatient Hospital No charge Dialysis/Hemodialysis office and outpatient hospital No charge Chemo/Radiation Therapy office and outpatient hospital No charge Skilled Nursing Care (facility) No charge Coverage is limited to 100 days per benefit period. Inpatient Hospice No charge Durable Medical Equipment No charge Prosthetic Devices No charge Page 4of9 Notes: • If you have an office visit with your Primary Care Physician, Specialist or Urgent Care at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under"Outpatient Facility Services". • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • Coverage includes standard fertility preservation services as a basic healthcare service including but are not limited to, injections, cryopreservation and storage for both male and female members when a medically necessary treatment may cause iatrogenic infertility. Member cost share for fertility preservation services is based on provider type and service rendered. • The representations of benefits in this document are subject to California Department of Insurance (DOI) approval and are subject to change. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail. Anthem Blue Cross is the trade name of Blue Cross of California.Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.®ANTHEM is a registered trademark of Anthem Insurance Companies,Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. Questions: (855) 333-5730 or visit us at www.anthem.com/ca Page 5 of 9 Your summary of benefits Anthem 0 Intentionally Left Blank Anthem,. Get help in your language BlueCross KD Notice of Language Assistance Curious to know what all this says?We would be too. Here's the English version: No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-888-254-2721. For more help call the CA Dept. of Insurance at 1-800-927-4357. (TTY/TDD: 711) Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. Spanish Servicios lingufsticos sin costo. Puede tener un interprete. Puede solicitar que le lean los documentos y algunos puede recibirlos en su idioma. Para obtener ayuda, Ilamenos al nOmero que figura en su tarjeta de identificacion o al 1-888-254- 2721. Para obtener ayuda adicional, Ilame al Departamento de Seguros de California al 1-800-927-4357. (TTY/TDD: 711) Arabic J J � J t jl 9 u11ii..011 v aa�3Ll I ja'`jt�4i1LL�oll �9 .r?�i.''0.�Lai.. l .1S v; - Lao J 9�4 ic111 uL o Li�1ai ea" .1-888-254-2721 �j)1 L,6 ji a—"U0 "yJ1 ,Ic- el)I.,6 L J.�1 (TTY/TDD: 711) .1-800-927-4357 ,jP JL.a,Y1 cb cL—J yjq J, Armenian fa-wpgJw'gwllwb iubq up 6wnwjmlalnmtrtrhp: Uhbp lluilinrl harp Qhq IauiligJwlu}h bwnwtntlajnLhhhp wnwpwpllhL LIwpnrl hhp tnpwtfwrlpht blq-np tfhlljrtr,nq tjrwutnwlarllahpp 44wprlw Qhq hwtfwp tr 4ntrlwp4b rlpwtrp Qhp thggnq: Ogtrntlajnth utnwtrwtnt hwtfwp gwhgwhwphp tfhq Qhq ID pwptnb 4 FLu bAW6 hhniu ijnuwhwt[wpnq tlwt[ 1-888-254-2721 hwt[wpnq: I,pwgnLq� oghntlajwh hwtfwp gwhgwhwphp 4uijt�nnh�wl�wulwhnquigpntlajwh hwluwpwpntlajnttr hhurhlwL hhnwlunuwhwtfwpnq 1-800-927-4357: (TTY/TDD: 711) Chinese AA PA PA Ar�5 Zft- - ZxtWj ate# 7� ��J ID P��7sl �, 1-888-254-2721�yµ Q �� tp �f A�#�171-800-927-4357 IR MCA Dept. of Insurance (TTY/TDD: 711) Farsi c5 I Y. 1 ) J U; 1 , . s 1 0.� tam I y.-3cs-a j--'j-�- LrA L-U ?�J-'-" LS__r .L i 1 9-ins-° •u�L-'j U LSD 1 L-.lu u -W J L.W_) I C j Lam_I �, j L�a g.. �j L-1 j A-q jam, a L-Lw I �)-! 9 ,1�I ¢L, L_o_w 1-888-254-2721 ,y-j}h j I L-j y 6 L�Ls--j L.o L c L -_) L S zw>.. 0_) L .A.;, J-J jb o, L_a_L a., Lam_, _ } � � am � } I_o L�I (TTY/TDD:711) uj L-o-3 1-800-927-4357 Hindi fiat wam *t 3TrgT #m#i 3T q ;F ftw wca zi7, Trq# t 1 3TPT qaw xw1 3T wu mw't 31Tgft um jk 94 7r wff# P ;r&;� * fAv, i* 3iq* ID W4 W *4T W wr 1-888-254-2721 W ch-161 ;EF;tI 3fftrw ;r&& * fc lv 1-800-927-4357 W CA tM ftM vc 441 1 (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 7of9 Hmong Tsis Xam Tus Nqi Cov Kev Pab Cuam Ntsig Txog Horn Lus.Koj muaj peev xwm tau txais ib tus neeg txhais lus.Koj muaj peev xwm tau txais cov ntaub ntawv nyeem ua koj horn lus rau koj mloog thiab yuav xa ib co ntaub ntawv sau ua koj horn lus tuaj rau koj. Txog rau kev pab,hu rau peb tus nab npawb xov tooj teev tseg cia nyob rau ntawm koj daim ID los sis 1-888-254-2721. Txog rau kev pab ntxiv, hu xov tooj rau Pab Kas Phais Lub Chaw Ua Hauj Lwm CA tus xov tooj 1-800-927-4357. (TTY/TDD: 711) Japanese -7 p -7 1_ { 21 + {� -7 } T} T1'FI PG I_Ao 7.�W\�—EA it G�1V��o ��7@F7 PGZ�a�GJL`T�If �)♦ 3Z!a�L�-il—EA-t 13j' ` 70 # Alf76lZlJ:, IDJi— FIZ ft tz f s, -at 1-888-254-2721 1Z8" < L 0o 3 #R0) �l�, t 1) 7t L, 71M4;T;,RP- (1-800-927-4357) IZ wA1< t::t LNo (TTY/TDD: 711) Khmer write MRRNRtfl9 ID 1- 888-254-2721, tAT9vrua9=i9v wv%tMvinigtvi CA Dept. of Insurance mutMO 1-800-927-4357,(TTY/TDD: 711) Korean T� Via{ �°�Pfz 01o6Fz' T °!dLI[F. �I�F°I Oa{ - - o�101 7�oi€I `A1z HFoF z' T 01 dLIEF. S Tz H.F0k121°2 ID 7F=Oil 71WEI t -L 1-888-254-2721-i�,'- ;EIQFoFd'AIQ. 1:1-z �-c2'F01 zgo1-.11T 1-800-927-4357 -Y o CA TM ail Q. (TTY/TDD: 711) Punjabi fi:>afi f z(ft F5'dT3 i�gw ftT;�tl 3H0 t'a Eut 4�Tu;a ue-TP�a�aV 3U-.4 -aw f:> d 3u-t 49 TTr T-r�- c725i wi -�Ft, Tpt 3c7r:a f M�ETJ-4 tETU Ft 1-888-254-2721 �4 ZF�-61`4I f:>F4FEr W�-�-5t, *,&f:>ZVa-c--KO-E Y4a f dOA 1-800-927-4357 �4-6177 Zftl (TTY/TDD: 711) Russian 6ecnnaTHble g3bIKOBbie ycnyrm. Bbl MO)KeTe nony4NTb ycnyrw yCTHOrO nepeBOgLIMKa. BaM MOryT np04NTaTb gOKymeHTbl mnm HanpaBMTb HeKOTOpble 1/13 HHX Ha BaWeM A3bIKe. ,QnFi nony4eHwq nOMOLLAN 3BOHNTe Ham no TeneCl3OHy, yKa3aHHOMy Ha BaWeM mgeHTWCpNKaL HOHHOO KapTe, mnm no HOMepy 1-888-254-2721. ,QnA nony4eHMq gononHVlTe.%HOV nOMOLL M 3BOHMTe B ,QenapTameHT CTpaxOBaHMq WTaTa KanHCl3OpHmP no Homepy 1-800-927-4357. (TTY/TDD: 711) Tagalog Mga Libreng Serbisyo para sa Wika. Maaari kayong kumuha ng interpreter. Maaari ninyong ipabasa ang mga dokumento at ipadala ang ilan sa mga ito sa inyo sa wikang ginagamit ninyo. Para sa tulong, tawagan kami sa numerong nakalista sa inyong ID card o sa 1-888-254-2721. Para sa higit pang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357. (TTY/TDD: 711) Thai "l�i�l�invsr�nsdfi€Iarivsln�� vinu��Ins€��IaZ�sysr�nsana�"l�i vinu�n�lns€��a°ivida�vlunvidnudar��s"l�ivi�u�vdt��dar��svnva€i��a��v€ivvi�u��€IZ�ss��la�vinu vinr��iavr��s�7na��ta€Id�aa �115G1�Y/1511i1651G119JVi9J1€J6s�21VIS�va€ivuti�sils�an�i721avvi�u�lsavivl�l�€16�21 1-888-254-2721 vl�t��iavr��s�7��1�t7€16�1aa6�%u�16�� 1YNR1Y/I''Y&) 1'1ULLrJun CA Dept. of Insurance V1AU1FRall 1-800-927-4357 (TTY/TDD: 711) Vietnamese Cac Dich Vu Ngon NgG, Mien Phi. Quy vi c6 the c6 thong dich vien. Quy vi co the yeu cau doc tai lieu cho quy vi nghe va yeu cau gui mot so tai lieu bang ngon ngCr cua quy vi cho quy vi. De duac tra giup, hay goi cho so duac ghi tren the ID cua quy vi hoac so 1-888-254-2721. De duac giup da them, hay goi cho Sa Bao Hiem California (California Department of Insurance)theo so 1-800-927-4357. (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 8of9 It's important we treat you fairly That's why we follow federal civil rights laws in our health programs and activities. We don't discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn't English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or online at https:Hocrportal.hhs.gov/ocr/portal/lobby.osf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 9of9 Your summary . benefits At em 0 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA)- County of Fresno: Custom EPO 500 Your Network: EPO FVisits with Virtual Care-Only Providersmobile Primary Care, and medical services for urgentlacute care $35 copay per visit Mental Health &Substance Use Disorder Services $35 copay per visit Specialist care $35 copay per visit Covered Medical Benefits Cost if you use an In-Network . - Overall Deductible $0 person Overall Out-of-Pocket Limit $3,000 person / $6,000 family To get benefits under this Plan, you must use In-Network Providers. Services from Non-Network Providers are not covered, except for Emergency Care, Authorized Services, or when required by law. Please be sure to contact us if you are not sure if we have approved an Authorized Service. The family out-of-pocket limit is embedded, meaning each covered person is capped at his or her per person out-of-pocket limit; in addition, cost shares for all covered family members apply to the family out-of-pocket limit, yet no one member will pay more than the per person out-of-pocket limit. All medical deductibles, copayments and coinsurance apply to the out-of-pocket limit. Doctor Visits (virtual and office) Your plan requires the selection of a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder $35 copay per visit Services virtual and office Specialist Care virtual and office $35 copay per visit Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) No charge Retail Health Clinic for routine care and treatment of common illnesses; $35 copay per visit usually found in major pharmacies or retail stores. CA/1.G/Custom EPO 500/6LW6/01-01-2024 Page 1 of 9 i MedicalCovered . - Manipulation Therapy $35 copay per visit Coverage is limited to 40 visits per benefit period. Acupuncture $35 copay per visit Other Services in an Office Allergy Testing No charge Prescription Drugs Dispensed in the office No charge Maximum of$250 member cost share per drug. Surgery No charge Preventive care 1 screenings 1 immunizations No charge Preventive Care for Chronic Conditions per IRS guidelines No charge Diagnostic Services Lab Office No charge Freestanding Lab No charge Outpatient Hospital No charge X-Ray Office No charge Freestanding Radiology Center No charge Outpatient Hospital No charge Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office No charge Freestanding Radiology Center No charge Outpatient Hospital No charge Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply $35 copay per visit depending on the care provided. Page 2of9 i MedicalCovered . - Emergency Room Facility Services In-Network and Non-Network Providers: Your copay will be waived if admitted. $250 copay per visit Emergency Room Doctor and Other Services In-Network and Non-Network Providers: No charge Ambulance In-Network and Non-Network Providers: Authorized Non-Network non-emergency ambulance services are limited No charge to an Anthem maximum payment of$50,000 per trip. Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees No charge Doctor Services No charge Outpatient Surgery Facility Fees Hospital No charge Ambulatory Surgical Center No charge Physician and other services including surgeon fees Hospital No charge Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) If readmitted within 72 hours for the same condition, no additional facility copay is required. If transferred between facilities, only one copay will apply. Facility Fees $500 copay per admission Physician and other services including surgeon fees No charge Home Health Care $35 copay per visit Coverage is limited to 100 visits per benefit period. Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical therapy, occupational therapy and speech therapy is limited to 60 days combined per benefit period. Office $35 copay per visit Page 3of9 i MedicalCovered . - Outpatient Hospital No charge Pulmonary rehabilitation Office $35 copay per visit Outpatient Hospital No charge Cardiac rehabilitation Office $35 copay per visit Outpatient Hospital No charge DialysislHemodialysis office and outpatient hospital No charge ChemolRadiation Therapy office and outpatient hospital No charge Skilled Nursing Care (facility) No charge Coverage is limited to 100 days per benefit period. Inpatient Hospice No charge Durable Medical Equipment No charge Prosthetic Devices. No charge Page 4of9 Notes: • If you have an office visit with your Primary Care Physician, Specialist or Urgent Care at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under"Outpatient Facility Services". • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • Coverage includes standard fertility preservation services as a basic healthcare service including but are not limited to, injections, cryopreservation and storage for both male and female members when a medically necessary treatment may cause iatrogenic infertility. Member cost share for fertility preservation services is based on provider type and service rendered. • The representations of benefits in this document are subject to California Department of Insurance (DOI) approval and are subject to change. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail. Anthem Blue Cross is the trade name of Blue Cross of California.Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.®ANTHEM is a registered trademark of Anthem Insurance Companies,Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. Questions: (855) 333-5730 or visit us at www.anthem.com/ca Page 5 of 9 Your summary of benefits Anthem 0 Intentionally Left Blank Anthem,. Get help in your language BlueCross KD Notice of Language Assistance Curious to know what all this says?We would be too. Here's the English version: No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-888-254-2721. For more help call the CA Dept. of Insurance at 1-800-927-4357. (TTY/TDD: 711) Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. Spanish Servicios lingufsticos sin costo. Puede tener un interprete. Puede solicitar que le lean los documentos y algunos puede recibirlos en su idioma. Para obtener ayuda, Ilamenos al nOmero que figura en su tarjeta de identificaci6n o al 1-888-254- 2721. Para obtener ayuda adicional, Ilame al Departamento de Seguros de California al 1-800-927-4357. (TTY/TDD: 711) Arabic J J � J t jl 9 u11ii..011 v aa��LI I ja'`jt�4i1LL�oll �9 .r?�i.''0.�Lai.. l .1S v; - Lao J 9�4 ic111 uL o Li�1ai ea" .1-888-254-2721 �j)1 L,6 ji a—"U I "yJ1 ,Ic- el)I.,6 L J.�1 (TTY/TDD: 711) .1-800-927-4357 ,jP JL.a,Y1 cs c�t o11 jq J, Armenian fa-wpgLfwiqw4wti uubq&up 6uuntntnLla]nLizhhp: Ulthp 4wpnrl hizp Qhq lawpgJwhjj hwr2WjnLlajnLhhhp LunU12Wp4lit LAupnIj hhp LnptuLfuurlphL hh�-np tf 4l h,nq Ljluuutntularllahpp 44Luprltu Qhq huudwp h 4nLrjwp4 rlpw ip Qhp thggnq: OgilnLlalnLb uLnLutLuuLnL hLUL[Lup gtuizgtuhwphp Lfhq Qhq ID pwptnh 4ptu'U2*uh hhnwjunuwhwJwpnq lltutf 1-888-254-2721 hwLfuupnq: I,ptugnLgh�oghnLla wh htutfwp gwhgwhwphp LIuiL� nntz�wju tuultuhntltugpnLlajUA1 huijuwptupnLlajni-h hhuihjtut hhntulunuwhwLfwpnq 1-800-927-4357: (TTY/TDD: 711) Chinese ate# 7� ��J ID ��Jsl �, 1-888-254-2721�yµ Q �� tpX��f�,� A�#�171-800-927-4357 90 MCA Dept. of Insurance (TTY/TDD: 711) Farsi ,5 I cs 5 m ? 19—ins—° •u�L-'j U LSD I ) .�Lo u j l .Say �s LJ u l y J �1 L.W� I t j L�l y U L� g i t j I j �r j Lew I )—! y ,L:u 19 t, Law 1-888-254-2721 ,y-j}h j I L.-j y 6 L�Ls--j L.o L c L -_) LS D a o r,..,��9 0_) L .A..;, ,g J jb a.) Law a., Lam_,)--9-"_J LS a � o, I I L� }w+a� �5 L-�5 a5 �3 Lam_) 5 I �, . ,L,} Fyn I o_, I_o L� (TTY/TDD:711) uj L-o-3 1-800-927-4357 Hindi fiat wam *t 3TrgT #m#i 3T q �A ftw wca zi7, Trq# t 1 31Tq qaw xw1 3T wu mw't 31Tgft um jk 94 7r wff# P ;r&;� * fAv, i* 3iq* ID W4 W *4T W wr 1-888-254-2721 W ch-161 ;EF;tI 3fftrw ;r&& * fc lv 1-800-927-4357 W CA tM ftM vc 441 1 (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 7of9 Hmong Tsis Xam Tus Nqi Cov Kev Pab Cuam Ntsig Txog Horn Lus.Koj muaj peev xwm tau txais ib tus neeg txhais lus.Koj muaj peev xwm tau txais cov ntaub ntawv nyeem ua koj horn lus rau koj mloog thiab yuav xa ib co ntaub ntawv sau ua koj horn lus tuaj rau koj. Txog rau kev pab,hu rau peb tus nab npawb xov tooj teev tseg cia nyob rau ntawm koj daim ID los sis 1-888-254-2721. Txog rau kev pab ntxiv, hu xov tooj rau Pab Kas Phais Lub Chaw Ua Hauj Lwm CA tus xov tooj 1-800-927-4357. (TTY/TDD: 711) Japanese -7 p -7 1_ { 21 + {� -7 } T} T1'FI PG I_Ao 7.�W\�—EA it G�1V��o ��7@F7 PGZ�a�GJL`T�If �)♦ 3Z!a�L�-il—EA-t 13j' ` 70 # Alf76lZlJ:, IDJi— FIZ ft tz f s, -at 1-888-254-2721 1Z8" < L 0o 3 #R0) �l�, t 1) 7t L, 71M4;T;,RP- (1-800-927-4357) IZ wA1< t::t LNo (TTY/TDD: 711) Khmer write MRRNRtfl9 ID 1- 888-254-2721, tAT9vrua9=i9v wv%tMvinigtvi CA Dept. of Insurance mutMO 1-800-927-4357,(TTY/TDD: 711) Korean T� Via{ �°�Pfz 01o6Fz' T °!dLI[F. �I�F°I Oa{ - - o�101 7�oi€I `A1z HFoF z' T 01 dLIEF. S Tz H.F0k121°2 ID 7F=Oil 71WEI t -L 1-888-254-2721-i�,'- ;EIQFoFd'AIQ. 1:1-z �-c2'F01 zgo1-.11T 1-800-927-4357 -Y o CA TM ail Q. (TTY/TDD: 711) Punjabi fi:>afi f z(ft F5'dT3 i�gw ftT;�tl 3H0 t'a Eut 4�Tu;a ue-TP�a�aV 3U-.4 -aw f:> d 3u-t 49 TTr T-r�- c725i wi -�Ft, Tpt 3c7r:a f M�ETJ-4 tETU Ft 1-888-254-2721 �4 ZF�-61`4I f:>F4FEr W�-�-5t, *,&f:>ZVa-c--KO-E Y4a f dOA 1-800-927-4357 �4-6177 Zftl (TTY/TDD: 711) Russian 6ecnnaTHble g3bIKOBbie ycnyrm. Bbl MO)KeTe nony4NTb ycnyrw yCTHOrO nepeBOgLIMKa. BaM MOryT np04NTaTb gOKymeHTbl mnm HanpaBMTb HeKOTOpble 1/13 HHX Ha BaWeM A3bIKe. ,QnFi nony4eHwq nOMOLLAN 3BOHNTe Ham no TeneCl3OHy, yKa3aHHOMy Ha BaWeM mgeHTWCpNKaL HOHHOO KapTe, mnm no HOMepy 1-888-254-2721. ,QnA nony4eHMq gononHVlTe.%HOV nOMOLL M 3BOHMTe B ,QenapTameHT CTpaxOBaHMq WTaTa KanHCl3OpHmP no Homepy 1-800-927-4357. (TTY/TDD: 711) Tagalog Mga Libreng Serbisyo para sa Wika. Maaari kayong kumuha ng interpreter. Maaari ninyong ipabasa ang mga dokumento at ipadala ang ilan sa mga ito sa inyo sa wikang ginagamit ninyo. Para sa tulong, tawagan kami sa numerong nakalista sa inyong ID card o sa 1-888-254-2721. Para sa higit pang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357. (TTY/TDD: 711) Thai "l�i�l�invsr�nsdfi€Iarivsln�� vinu��Ins€��IaZ�sysr�nsana�"l�i vinu�n�lns€��a°ivida�vlunvidnudar��s"l�ivi�u�vdt��dar��svnva€i��a��v€ivvi�u��€IZ�ss��la�vinu vinr��iavr��s�7na��ta€Id�aa �115G1�Y/1511i1651G119JVi9J1€J6s�21VIS�va€ivuti�sils�an�i721avvi�u�lsavivl�l�€16�21 1-888-254-2721 vl�t��iavr��s�7��1�t7€16�1aa6�%u�16�� 1YNR1Y/I''Y&) 1'1ULLrJun CA Dept. of Insurance V1AU1FRall 1-800-927-4357 (TTY/TDD: 711) Vietnamese Cac Dich Vu Ngon NgG, Mien Phi. Quy vi c6 the c6 thong dich vien. Quy vi co the yeu cau doc tai lieu cho quy vi nghe va yeu cau gui mot so tai lieu bang ngon ngCr cua quy vi cho quy vi. De duac tra giup, hay goi cho so duac ghi tren the ID cua quy vi hoac so 1-888-254-2721. De duac giup da them, hay goi cho Sa Bao Hiem California (California Department of Insurance)theo so 1-800-927-4357. (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 8of9 It's important we treat you fairly That's why we follow federal civil rights laws in our health programs and activities. We don't discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn't English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or online at https:Hocrportal.hhs.gov/ocr/portal/lobby.osf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 9of9 Your summary . benefits At em 0 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA)- County of Fresno - Custom EPO 1000 Your Network: EPO Care-OnlyFVisits with Virtual . . mobile Primary Care, and medical services for urgentlacute care $0 Mental Health &Substance Use Disorder Services $0 Specialist care $35 copay per visit Covered Medical Benefits Cost if you use an In-Network . - Overall Deductible $0 person Overall Out-of-Pocket Limit $4,000 person / $8,000 family To get benefits under this Plan, you must use In-Network Providers. Services from Non-Network Providers are not covered, except for Emergency, Authorized Services, or when required by law. Please be sure to contact us if you are not sure if we have approved an Authorized Service. The family out-of-pocket limit is embedded, meaning each covered person is capped at his or her per person out-of-pocket limit; in addition, cost shares for all covered family members apply to the family out-of-pocket limit, yet no one member will pay more than the per person out-of-pocket limit. All medical deductibles, copayments and coinsurance apply to the out-of-pocket limit. Doctor Visits (virtual and office) Your plan requires the selection of a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder $35 copay per visit Services virtual and office Specialist Care virtual and office $35 copay per visit Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) No charge Retail Health Clinic for routine care and treatment of common illnesses; $35 copay per visit usually found in major pharmacies or retail stores. Manipulation Therapy $35 copay per visit CA/1.G/Custom EPO 1000/52KU/01-01-2024 Page 1 of 9 i MedicalCovered Coverage is limited to 40 visits per benefit period. Acupuncture $35 copay per visit Other Services in an Office Allergy Testing No charge Prescription Drugs Dispensed in the office No charge Maximum of$250 member cost share per drug. Surgery No charge Preventive care I screenings 1 immunizations No charge Preventive Care for Chronic Conditions per IRS guidelines No charge Diagnostic Services Lab Office No charge Freestanding Lab No charge Outpatient Hospital No charge X-Ray Office No charge Freestanding Radiology Center No charge Outpatient Hospital No charge Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office No charge Freestanding Radiology Center No charge Outpatient Hospital No charge i Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply depending on the care provided. $35 copay per visit Page 2of9 i MedicalCovered Emergency Room Facility Services In-Network and Non-Network Providers: Your copay will be waived if admitted. $300 copay per visit Emergency Room Doctor and Other Services In-Network and Non-Network Providers: No charge Ambulance In-Network and Non-Network Providers: Authorized Non-Network non-emergency ambulance services are limited No charge to an Anthem maximum payment of$50,000 per trip. Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees No charge Doctor Services No charge k I Outpatient Surgery Facility Fees Hospital No charge Ambulatory Surgical Center No charge Physician and other services including surgeon fees Hospital No charge Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) If readmitted within 72 hours for the same condition, no additional facility copay is required. If transferred between facilities, only one copay will apply. Facility Fees $1,000 copay per admission Physician and other services including surgeon fees No charge Home Health Care $35 copay per visit Coverage is limited to 100 visits per benefit period. Rehabilitation and Habilitation services including physical, occupational and speech therapies. Coverage for physical, occupational and speech therapies is limited to 60 days combined per benefit period. Office $35 copay per visit Outpatient Hospital No charge Page 3of9 i MedicalCovered Pulmonary rehabilitation Office $35 copay per visit Outpatient Hospital No charge Cardiac rehabilitation Office $35 copay per visit Outpatient Hospital No charge Dialysis/Hemodialysis office and outpatient hospital No charge Chemo/Radiation Therapy office and outpatient hospital No charge Skilled Nursing Care (facility) No charge Coverage is limited to 100 days per benefit period. Inpatient Hospice No charge Durable Medical Equipment No charge Prosthetic Devices No charge Coverage for wigs is limited to 1 item after cancer treatment per benefit period. Hearing Aids No charge Coverage is limited to 1 item per ear every 3 years. Page 4of9 Notes: • If you have an office visit with your Primary Care Physician, Specialist or Urgent Care at an Outpatient Facility (e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under"Outpatient Facility Services". • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • Coverage includes standard fertility preservation services as a basic healthcare service including but are not limited to, injections, cryopreservation and storage for both male and female members when a medically necessary treatment may cause iatrogenic infertility. Member cost share for fertility preservation services is based on provider type and service rendered. • The representations of benefits in this document are subject to California Department of Insurance (DOI) approval and are subject to change. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail. Anthem Blue Cross is the trade name of Blue Cross of California.Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.®ANTHEM is a registered trademark of Anthem Insurance Companies,Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. Questions: (855) 333-5730 or visit us at www.anthem.com/ca Page 5 of 9 Your summary of benefits Anthem 0 Intentionally Left Blank Anthem,. Get help in your language BlueCross KD Notice of Language Assistance Curious to know what all this says?We would be too. Here's the English version: No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-888-254-2721. For more help call the CA Dept. of Insurance at 1-800-927-4357. (TTY/TDD: 711) Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. Spanish Servicios lingufsticos sin costo. Puede tener un interprete. Puede solicitar que le lean los documentos y algunos puede recibirlos en su idioma. Para obtener ayuda, Ilamenos al nOmero que figura en su tarjeta de identificacion o al 1-888-254- 2721. Para obtener ayuda adicional, Ilame al Departamento de Seguros de California al 1-800-927-4357. (TTY/TDD: 711) Arabic J J � J t jl 9 u11ii..011 v aa�3Ll I ja'`jt�4i1LL�oll �9 .r?�i.''0.�Lai.. l .1S v; - Lao J 9�4 ic111 uL o Li�1ai ea" .1-888-254-2721 �j)1 L,6 ji a—"U0 "yJ1 ,Ic- el)I.,6 L J.�1 (TTY/TDD: 711) .1-800-927-4357 ,jP JL.a,Y1 cb cL—J yjq J, Armenian fa-wpgJw'gwllwb iubq up 6wnwjmlalnmtrtrhp: Uhbp lluilinrl harp Qhq IauiligJwlu}h bwnwtntlajnLhhhp wnwpwpllhL LIwpnrl hhp tnpwtfwrlpht blq-np tfhlljrtr,nq tjrwutnwlarllahpp 44wprlw Qhq hwtfwp tr 4ntrlwp4b rlpwtrp Qhp thggnq: Ogtrntlajnth utnwtrwtnt hwtfwp gwhgwhwphp tfhq Qhq ID pwptnb 4 FLu bAW6 hhniu ijnuwhwt[wpnq tlwt[ 1-888-254-2721 hwt[wpnq: I,pwgnLq� oghntlajwh hwtfwp gwhgwhwphp 4uijt�nnh�wl�wulwhnquigpntlajwh hwluwpwpntlajnttr hhurhlwL hhnwlunuwhwtfwpnq 1-800-927-4357: (TTY/TDD: 711) Chinese AA PA PA Ar�5 Zft- - ZxtWj ate# 7� ��J ID P��7sl �, 1-888-254-2721�yµ Q �� tp �f A�#�171-800-927-4357 IR MCA Dept. of Insurance (TTY/TDD: 711) Farsi c5 I Y. 1 ) J U; 1 , . s 1 0.� tam I y.-3cs-a j--'j-�- LrA L-U ?�J-'-" LS__r .L i 1 9-ins-° •u�L-'j U LSD 1 L-.lu u -W J L.W_) I C j Lam_I �, j L�a g.. �j L-1 j A-q jam, a L-Lw I �)-! 9 ,1�I ¢L, L_o_w 1-888-254-2721 ,y-j}h j I L-j y 6 L�Ls--j L.o L c L -_) L S zw>.. 0_) L .A.;, J-J jb o, L_a_L a., Lam_, _ } � � am � } I_o L�I (TTY/TDD:711) uj L-o-3 1-800-927-4357 Hindi fiat wam *t 3TrgT #m#i 3T q ;F ftw wca zi7, Trq# t 1 3TPT qaw xw1 3T wu mw't 31Tgft um jk 94 7r wff# P ;r&;� * fAv, i* 3iq* ID W4 W *4T W wr 1-888-254-2721 W ch-161 ;EF;tI 3fftrw ;r&& * fc lv 1-800-927-4357 W CA tM ftM vc 441 1 (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 7of9 Hmong Tsis Xam Tus Nqi Cov Kev Pab Cuam Ntsig Txog Horn Lus.Koj muaj peev xwm tau txais ib tus neeg txhais lus.Koj muaj peev xwm tau txais cov ntaub ntawv nyeem ua koj horn lus rau koj mloog thiab yuav xa ib co ntaub ntawv sau ua koj horn lus tuaj rau koj. Txog rau kev pab,hu rau peb tus nab npawb xov tooj teev tseg cia nyob rau ntawm koj daim ID los sis 1-888-254-2721. Txog rau kev pab ntxiv, hu xov tooj rau Pab Kas Phais Lub Chaw Ua Hauj Lwm CA tus xov tooj 1-800-927-4357. (TTY/TDD: 711) Japanese -7 p -7 1_ { 21 + {� -7 } T} T1'FI PG I_Ao 7.�W\�—EA it G�1V��o ��7@F7 PGZ�a�GJL`T�If �)♦ 3Z!a�L�-il—EA-t 13j' ` 70 # Alf76lZlJ:, IDJi— FIZ ft tz f s, -at 1-888-254-2721 1Z8" < L 0o 3 #R0) �l�, t 1) 7t L, 71M4;T;,RP- (1-800-927-4357) IZ wA1< t::t LNo (TTY/TDD: 711) Khmer write MRRNRtfl9 ID 1- 888-254-2721, tAT9vrua9=i9v wv%tMvinigtvi CA Dept. of Insurance mutMO 1-800-927-4357,(TTY/TDD: 711) Korean T� Via{ �°�Pfz 01o6Fz' T °!dLI[F. �I�F°I Oa{ - - o�101 7�oi€I `A1z HFoF z' T 01 dLIEF. S Tz H.F0k121°2 ID 7F=Oil 71WEI t -L 1-888-254-2721-i�,'- ;EIQFoFd'AIQ. 1:1-z �-c2'F01 zgo1-.11T 1-800-927-4357 -Y o CA TM ail Q. (TTY/TDD: 711) Punjabi fi:>afi f z(ft F5'dT3 i�gw ftT;�tl 3H0 t'a Eut 4�Tu;a ue-TP�a�aV 3U-.4 -aw f:> d 3u-t 49 TTr T-r�- c725i wi -�Ft, Tpt 3c7r:a f M�ETJ-4 tETU Ft 1-888-254-2721 �4 ZF�-61`4I f:>F4FEr W�-�-5t, *,&f:>ZVa-c--KO-E Y4a f dOA 1-800-927-4357 �4-6177 Zftl (TTY/TDD: 711) Russian 6ecnnaTHble g3bIKOBbie ycnyrm. Bbl MO)KeTe nony4NTb ycnyrw yCTHOrO nepeBOgLIMKa. BaM MOryT np04NTaTb gOKymeHTbl mnm HanpaBMTb HeKOTOpble 1/13 HHX Ha BaWeM A3bIKe. ,QnFi nony4eHwq nOMOLLAN 3BOHNTe Ham no TeneCl3OHy, yKa3aHHOMy Ha BaWeM mgeHTWCpNKaL HOHHOO KapTe, mnm no HOMepy 1-888-254-2721. ,QnA nony4eHMq gononHVlTe.%HOV nOMOLL M 3BOHMTe B ,QenapTameHT CTpaxOBaHMq WTaTa KanHCl3OpHmP no Homepy 1-800-927-4357. (TTY/TDD: 711) Tagalog Mga Libreng Serbisyo para sa Wika. Maaari kayong kumuha ng interpreter. Maaari ninyong ipabasa ang mga dokumento at ipadala ang ilan sa mga ito sa inyo sa wikang ginagamit ninyo. Para sa tulong, tawagan kami sa numerong nakalista sa inyong ID card o sa 1-888-254-2721. Para sa higit pang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357. (TTY/TDD: 711) Thai "l�i�l�invsr�nsdfi€Iarivsln�� vinu��Ins€��IaZ�sysr�nsana�"l�i vinu�n�lns€��a°ivida�vlunvidnudar��s"l�ivi�u�vdt��dar��svnva€i��a��v€ivvi�u��€IZ�ss��la�vinu vinr��iavr��s�7na��ta€Id�aa �115G1�Y/1511i1651G119JVi9J1€J6s�21VIS�va€ivuti�sils�an�i721avvi�u�lsavivl�l�€16�21 1-888-254-2721 vl�t��iavr��s�7��1�t7€16�1aa6�%u�16�� 1YNR1Y/I''Y&) 1'1ULLrJun CA Dept. of Insurance V1AU1FRall 1-800-927-4357 (TTY/TDD: 711) Vietnamese Cac Dich Vu Ngon NgG, Mien Phi. Quy vi c6 the c6 thong dich vien. Quy vi co the yeu cau doc tai lieu cho quy vi nghe va yeu cau gui mot so tai lieu bang ngon ngCr cua quy vi cho quy vi. De duac tra giup, hay goi cho so duac ghi tren the ID cua quy vi hoac so 1-888-254-2721. De duac giup da them, hay goi cho Sa Bao Hiem California (California Department of Insurance)theo so 1-800-927-4357. (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 8of9 It's important we treat you fairly That's why we follow federal civil rights laws in our health programs and activities. We don't discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn't English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or online at https:Hocrportal.hhs.gov/ocr/portal/lobby.osf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 9of9 Your summary . benefits At em 0 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA) — County of Fresno: PPO 250 Your Network: Prudent Buyer PPO Care-OnlyVisits with Virtual . . mobile Primary Care, and medical services for urgent/acute care $20 copay per visit deductible does not apply Mental Health &Substance Use Disorder Services $20 copay per visit deductible does not apply Specialist care $20 copay per visit deductible does not apply Cost if you use an In- Cost if you use a Covered Medical Benefits Network Provider Non-Network AL Provider ima Overall Deductible $250 person I $250 person I $500 family $500 family Overall Out-of-Pocket Limit $3,000 person / $10,000 person I $5,000 family $15,000 family The family deductible is non-embedded, meaning when more than a single person is enrolled, the per person deductible does not apply and the family deductible must be met by any one person or collection of persons. The out-of-pocket limit is embedded, meaning each covered person is capped at his or her per person out-of-pocket limit. All medical deductibles, copayments and coinsurance apply to the out-of-pocket limit. In-Network and Non-Network deductibles are combined and accumulate toward each other; however In-Network and Non- Network out-of-pocket limit amounts accumulate separately and do not accumulate toward each other. Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder $20 copay per visit 50% coinsurance after Services virtual and office deductible does not deductible is met apply Specialist Care virtual and office $20 copay per visit 50% coinsurance after deductible does not deductible is met apply Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) No charge after 50% coinsurance after deductible is met deductible is met CA/1.G/PPO 250/OU91/01-01-2024 Page 1 of 9 i CoveredCost if you use an In- Cost if you use a Medical Provider Retail Health Clinic for routine care and treatment of common illnesses; $20 copay per visit 50% coinsurance after usually found in major pharmacies or retail stores. deductible does not deductible is met apply Manipulation Therapy No charge after 50% coinsurance after Coverage is limited to 24 visits per benefit period. deductible is met deductible is met Acupuncture No charge after 50% coinsurance after Coverage is limited to 12 visits perbenefit period. deductible is met deductible is met Other Services in an Office Allergy Testing No charge after 50% coinsurance after deductible is met deductible is met Prescription Drugs Dispensed in the office No charge after 50% coinsurance after Maximum of$250 member cost share per drug. deductible is met deductible is met Surgery No charge after 50% coinsurance after deductible is met deductible is met Preventive care I screenings 1 immunizations No charge 50% coinsurance after deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge 50% coinsurance after deductible is met Diagnostic Services Lab Office No charge after 50% coinsurance after deductible is met deductible is met Freestanding Lab No charge after 50% coinsurance after deductible is met deductible is met Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible is met X-Ray Office No charge after 50% coinsurance after deductible is met deductible is met Freestanding Radiology Center No charge after 50% coinsurance after deductible is met deductible is met Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible is met Advanced Diagnostic Imaging for example:MRI, PET and CAT scans Office No charge after 50% coinsurance after deductible is met deductible is met Page 2of9 i CoveredCost if you use an In- Cost if you use a Medical �Illlllllj Provider 9 Freestanding Radiology Center No charge after 50% coinsurance after deductible is met deductible is met Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible is met Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply $20 copay per visit 50% coinsurance after depending on the care provided. deductible does not deductible is met apply Emergency Room Facility Services No charge after Covered as In-Network $100 deductible waived if admitted directly from ER. deductible is met Emergency Room Doctor and Other Services No charge after Covered as In-Network deductible is met Ambulance No charge after Covered as In-Network deductible is met Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees No charge after 50% coinsurance after deductible is met deductible is met Doctor Services No charge after 50% coinsurance after deductible is met deductible is met Outpatient Surgery Facility Fees Hospital No charge after 50% coinsurance after deductible is met deductible is met Ambulatory Surgical Center No charge after 50% coinsurance after deductible is met deductible is met Physician and other services including surgeon fees Hospital No charge after 50% coinsurance after deductible is met deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) Anthem's maximum payment is up to $500 per services for non- emergency Inpatient admissions to non-network providers. Facility Fees No charge after 50% coinsurance after deductible is met deductible is met Physician and other services including surgeon fees No charge after 50% coinsurance after deductible is met deductible is met Page 3of9 i CoveredCost if you use an In- Cost if you use a Medical Provider Home Health Care No charge after 50% coinsurance after Coverage is limited to 100 visits per benefit period. deductible is met deductible is met Rehabilitation and Habilitation services including physical, occupational and speech therapies. Office No charge after 50% coinsurance after deductible is met deductible is met Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible is met Pulmonary rehabilitation office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met Cardiac rehabilitation office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met DialysislHemodialysis office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met ChemolRadiation Therapy office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met Skilled Nursing Care (facility) No charge after 50% coinsurance after Coverage is limited to 100 days per benefit period. deductible is met deductible is met Inpatient Hospice No charge after No charge after deductible is met deductible is met Durable Medical Equipment No charge after 50% coinsurance after deductible is met deductible is met Prosthetic Devices No charge after 50% coinsurance after deductible is met deductible is met Page 4of9 Notes: • If you have an office visit with your Primary Care Physician, Specialist or Urgent Care at an Outpatient Facility(e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under"Outpatient Facility Services". • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • Outpatient Facility tests and treatments are limited to$350 per admission for Non-Network Providers. Includes: Diagnostic Services; X-ray; Surgery; Rehabilitation; Habilitation; Cardiac Therapy; Surgery at Ambulatory Surgical Centers. • Coverage includes standard fertility preservation services as a basic healthcare service including but are not limited to, injections, cryo preservation and storage for both male and female members when a medically necessary treatment may cause iatrogenic infertility. Member cost share for fertility preservation services is based on provider type and service rendered. • The representations of benefits in this document are subject to California Department of Insurance (DOI) approval and are subject to change. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail. Anthem Blue Cross is the trade name of Blue Cross of California.Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.®ANTHEM is a registered trademark of Anthem Insurance Companies,Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. Questions: (855) 333-5730 or visit us at www.anthem.com/ca Page 5 of 9 Your summary of benefits Anthem 0 Intentionally Left Blank Anthem,. Get help in your language BlueCross KD Notice of Language Assistance Curious to know what all this says?We would be too. Here's the English version: No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-888-254-2721. For more help call the CA Dept. of Insurance at 1-800-927-4357. (TTY/TDD: 711) Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. Spanish Servicios lingufsticos sin costo. Puede tener un interprete. Puede solicitar que le lean los documentos y algunos puede recibirlos en su idioma. Para obtener ayuda, Ilamenos al nOmero que figura en su tarjeta de identificacion o al 1-888-254- 2721. Para obtener ayuda adicional, Ilame al Departamento de Seguros de California al 1-800-927-4357. (TTY/TDD: 711) Arabic J J � J t jl 9 u11ii..011 v aa�3Ll I ja'`jt�4i1LL�oll �9 .r?�i.''0.�Lai.. l .1S v; - Lao J 9�4 ic111 uL o Li�1ai ea" .1-888-254-2721 �j)1 L,6 ji a—"U0 "yJ1 ,Ic- el)I.,6 L J.�1 (TTY/TDD: 711) .1-800-927-4357 ,jP JL.a,Y1 cb cL—J yjq J, Armenian fa-wpgJw'gwllwb iubq up 6wnwjmlalnmtrtrhp: Uhbp lluilinrl harp Qhq IauiligJwlu}h bwnwtntlajnLhhhp wnwpwpllhL LIwpnrl hhp tnpwtfwrlpht blq-np tfhlljrtr,nq tjrwutnwlarllahpp 44wprlw Qhq hwtfwp tr 4ntrlwp4b rlpwtrp Qhp thggnq: Ogtrntlajnth utnwtrwtnt hwtfwp gwhgwhwphp tfhq Qhq ID pwptnb 4 FLu bAW6 hhniu ijnuwhwt[wpnq tlwt[ 1-888-254-2721 hwt[wpnq: I,pwgnLq� oghntlajwh hwtfwp gwhgwhwphp 4uijt�nnh�wl�wulwhnquigpntlajwh hwluwpwpntlajnttr hhurhlwL hhnwlunuwhwtfwpnq 1-800-927-4357: (TTY/TDD: 711) Chinese AA PA PA Ar�5 Zft- - ZxtWj ate# 7� ��J ID P��7sl �, 1-888-254-2721�yµ Q �� tp �f A�#�171-800-927-4357 IR MCA Dept. of Insurance (TTY/TDD: 711) Farsi c5 I Y. 1 ) J U; 1 , . s 1 0.� tam I y.-3cs-a j--'j-�- LrA L-U ?�J-'-" LS__r .L i 1 9-ins-° •u�L-'j U LSD 1 L-.lu u -W J L.W_) I C j Lam_I �, j L�a g.. �j L-1 j A-q jam, a L-Lw I �)-! 9 ,1�I ¢L, L_o_w 1-888-254-2721 ,y-j}h j I L-j y 6 L�Ls--j L.o L c L -_) L S zw>.. 0_) L .A.;, J-J jb o, L_a_L a., Lam_, _ } � � am � } I_o L�I (TTY/TDD:711) uj L-o-3 1-800-927-4357 Hindi fiat wam *t 3TrgT #m#i 3T q ;F ftw wca zi7, Trq# t 1 3TPT qaw xw1 3T wu mw't 31Tgft um jk 94 7r wff# P ;r&;� * fAv, i* 3iq* ID W4 W *4T W wr 1-888-254-2721 W ch-161 ;EF;tI 3fftrw ;r&& * fc lv 1-800-927-4357 W CA tM ftM vc 441 1 (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 7of9 Hmong Tsis Xam Tus Nqi Cov Kev Pab Cuam Ntsig Txog Horn Lus.Koj muaj peev xwm tau txais ib tus neeg txhais lus.Koj muaj peev xwm tau txais cov ntaub ntawv nyeem ua koj horn lus rau koj mloog thiab yuav xa ib co ntaub ntawv sau ua koj horn lus tuaj rau koj. Txog rau kev pab,hu rau peb tus nab npawb xov tooj teev tseg cia nyob rau ntawm koj daim ID los sis 1-888-254-2721. Txog rau kev pab ntxiv, hu xov tooj rau Pab Kas Phais Lub Chaw Ua Hauj Lwm CA tus xov tooj 1-800-927-4357. (TTY/TDD: 711) Japanese -7 p -7 1_ { 21 + {� -7 } T} T1'FI PG I_Ao 7.�W\�—EA it G�1V��o ��7@F7 PGZ�a�GJL`T�If �)♦ 3Z!a�L�-il—EA-t 13j' ` 70 # Alf76lZlJ:, IDJi— FIZ ft tz f s, -at 1-888-254-2721 1Z8" < L 0o 3 #R0) �l�, t 1) 7t L, 71M4;T;,RP- (1-800-927-4357) IZ wA1< t::t LNo (TTY/TDD: 711) Khmer write MRRNRtfl9 ID 1- 888-254-2721, tAT9vrua9=i9v wv%tMvinigtvi CA Dept. of Insurance mutMO 1-800-927-4357,(TTY/TDD: 711) Korean T� Via{ �°�Pfz 01o6Fz' T °!dLI[F. �I�F°I Oa{ - - o�101 7�oi€I `A1z HFoF z' T 01 dLIEF. S Tz H.F0k121°2 ID 7F=Oil 71WEI t -L 1-888-254-2721-i�,'- ;EIQFoFd'AIQ. 1:1-z �-c2'F01 zgo1-.11T 1-800-927-4357 -Y o CA TM ail Q. (TTY/TDD: 711) Punjabi fi:>afi f z(ft F5'dT3 i�gw ftT;�tl 3H0 t'a Eut 4�Tu;a ue-TP�a�aV 3U-.4 -aw f:> d 3u-t 49 TTr T-r�- c725i wi -�Ft, Tpt 3c7r:a f M�ETJ-4 tETU Ft 1-888-254-2721 �4 ZF�-61`4I f:>F4FEr W�-�-5t, *,&f:>ZVa-c--KO-E Y4a f dOA 1-800-927-4357 �4-6177 Zftl (TTY/TDD: 711) Russian 6ecnnaTHble g3bIKOBbie ycnyrm. Bbl MO)KeTe nony4NTb ycnyrw yCTHOrO nepeBOgLIMKa. BaM MOryT np04NTaTb gOKymeHTbl mnm HanpaBMTb HeKOTOpble 1/13 HHX Ha BaWeM A3bIKe. ,QnFi nony4eHwq nOMOLLAN 3BOHNTe Ham no TeneCl3OHy, yKa3aHHOMy Ha BaWeM mgeHTWCpNKaL HOHHOO KapTe, mnm no HOMepy 1-888-254-2721. ,QnA nony4eHMq gononHVlTe.%HOV nOMOLL M 3BOHMTe B ,QenapTameHT CTpaxOBaHMq WTaTa KanHCl3OpHmP no Homepy 1-800-927-4357. (TTY/TDD: 711) Tagalog Mga Libreng Serbisyo para sa Wika. Maaari kayong kumuha ng interpreter. Maaari ninyong ipabasa ang mga dokumento at ipadala ang ilan sa mga ito sa inyo sa wikang ginagamit ninyo. Para sa tulong, tawagan kami sa numerong nakalista sa inyong ID card o sa 1-888-254-2721. Para sa higit pang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357. (TTY/TDD: 711) Thai "l�i�l�invsr�nsdfi€Iarivsln�� vinu��Ins€��IaZ�sysr�nsana�"l�i vinu�n�lns€��a°ivida�vlunvidnudar��s"l�ivi�u�vdt��dar��svnva€i��a��v€ivvi�u��€IZ�ss��la�vinu vinr��iavr��s�7na��ta€Id�aa �115G1�Y/1511i1651G119JVi9J1€J6s�21VIS�va€ivuti�sils�an�i721avvi�u�lsavivl�l�€16�21 1-888-254-2721 vl�t��iavr��s�7��1�t7€16�1aa6�%u�16�� 1YNR1Y/I''Y&) 1'1ULLrJun CA Dept. of Insurance V1AU1FRall 1-800-927-4357 (TTY/TDD: 711) Vietnamese Cac Dich Vu Ngon NgG, Mien Phi. Quy vi c6 the c6 thong dich vien. Quy vi co the yeu cau doc tai lieu cho quy vi nghe va yeu cau gui mot so tai lieu bang ngon ngCr cua quy vi cho quy vi. De duac tra giup, hay goi cho so duac ghi tren the ID cua quy vi hoac so 1-888-254-2721. De duac giup da them, hay goi cho Sa Bao Hiem California (California Department of Insurance)theo so 1-800-927-4357. (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 8of9 It's important we treat you fairly That's why we follow federal civil rights laws in our health programs and activities. We don't discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn't English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1- 800-537-7697) or online at https:Hocrportal.hhs.gov/ocr/portal/lobby.osf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.html. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CDI3 CDIW1 #CA-CDI-001 Page 9of9 Your summary of benefits �mthem 0 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA) — County of Fresno- PPO HDHP 1500 Your Network: Prudent Buyer PPO Visits with Virtual Care-Only Providers Cost through our mobile app and website Primary Care, and medical services for urgent/acute care No charge after deductible is met Mental Health &Substance Use Disorder Services No charge after deductible is met Specialist care No charge after deductible is met Cost if you use an In- Cost if you use a Covered Medical Benefits Network Provider Non-Network Provider ��i Overall Deductible $1,500 individual / $1,500 individual I $3,000 member/ $3,000 member/ $3,000 family $3,000 family Overall Out-of-Pocket Limit $3,000 individual / $10,000 individual / $5,000 family $15,000 family The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per person deductible and per person out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per person deductible or per person out-of-pocket limit. All medical deductibles, copayments and coinsurance apply to the out-of-pocket limit. In-Network and Non-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other. Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder 20% coinsurance after 40% coinsurance after Services virtual and office deductible is met deductible is met Specialist Care virtual and office 20% coinsurance after 40% coinsurance after deductible is met deductible is met Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) 20% coinsurance after 40% coinsurance after deductible is met deductible is met CA/LG/Anthem PPO (HDHP) 1500/48D3/01-01-2024 Page 1 of 9 i CoveredCost if you use an In- Cost if you use a Medical Provider Retail Health Clinic for routine care and treatment of common illnesses; 20% coinsurance after 40% coinsurance after usually found in major pharmacies or retail stores. deductible is met deductible is met Manipulation Therapy 20% coinsurance after 40% coinsurance after Coverage is limited to 24 visits per benefit period. deductible is met deductible is met Acupuncture 20% coinsurance after 40% coinsurance after Coverage is limited to 12 visits per benefit period. deductible is met deductible is met Other Services in an Office Allergy Testing 20% coinsurance after 40% coinsurance after deductible is met deductible is met Prescription Drugs Dispensed in the office 30% coinsurance after 40% coinsurance after Maximum of$250 member cost share per drug. deductible is met deductible is met Surgery 20% coinsurance after 40% coinsurance after deductible is met deductible is met Preventive care 1 screenings 1 immunizations No charge 40% coinsurance after deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge 40% coinsurance after deductible is met Diagnostic Services Lab Office 20% coinsurance after 40% coinsurance after deductible is met deductible is met Freestanding Lab 20% coinsurance after 40% coinsurance after deductible is met deductible is met Outpatient Hospital 20% coinsurance after 40% coinsurance after deductible is met deductible is met X-Ray Office 20% coinsurance after 40% coinsurance after deductible is met deductible is met Freestanding Radiology Center 20% coinsurance after 40% coinsurance after deductible is met deductible is met Outpatient Hospital 20% coinsurance after 40% coinsurance after deductible is met deductible is met Advanced Diagnostic Imaging for example:MRI, PET and CAT scans Office 20% coinsurance after 40% coinsurance after deductible is met deductible is met Page 2 of 9 CoveredCost if you use an In- Cost if you use a Medical Provider j6L Freestanding Radiology Center 20% coinsurance after 40% coinsurance after deductible is met deductible is met Outpatient Hospital 20% coinsurance after 40% coinsurance after deductible is met deductible is met Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply 20% coinsurance after 40% coinsurance after depending on the care provided. deductible is met deductible is met Emergency Room Facility Services 20% coinsurance after Covered as In-Network deductible is met Emergency Room Doctor and Other Services 20% coinsurance after Covered as In-Network deductible is met Ambulance 20% coinsurance after Covered as In-Network deductible is met Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees 20% coinsurance after 40% coinsurance after deductible is met deductible is met Doctor Services 20% coinsurance after 40% coinsurance after deductible is met deductible is met Outpatient Surgery Facility Fees Hospital 20% coinsurance after 40% coinsurance after deductible is met deductible is met Ambulatory Surgical Center 20% coinsurance after 40% coinsurance after deductible is met deductible is met Physician and other services including surgeon fees Hospital 20% coinsurance after 40% coinsurance after deductible is met deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) Facility Fees 20% coinsurance after 40% coinsurance after deductible is met deductible is met Physician and other services including surgeon fees 20% coinsurance after 40% coinsurance after deductible is met deductible is met Page 3 of 9 CoveredCost if you use an In- Cost if you use a Medical Provider Home Health Care 20% coinsurance after 40% coinsurance after Coverage is limited to 100 visits per benefit period. deductible is met deductible is met Rehabilitation and Habilitation services including physical, occupational and speech therapies. Office 20% coinsurance after 40% coinsurance after deductible is met deductible is met Outpatient Hospital 20% coinsurance after 40% coinsurance after deductible is met deductible is met Pulmonary rehabilitation office and outpatient hospital 20% coinsurance after 40% coinsurance after deductible is met deductible is met Cardiac rehabilitation office and outpatient hospital 20% coinsurance after 40% coinsurance after deductible is met deductible is met Dialysis/Hemodialysis office and outpatient hospital 20% coinsurance after 40% coinsurance after deductible is met deductible is met Chemo/Radiation Therapy office and outpatient hospital 20% coinsurance after 40% coinsurance after deductible is met deductible is met Skilled Nursing Care (facility) 20% coinsurance after 40% coinsurance after Coverage is limited to 100 days per benefit period. deductible is met deductible is met Inpatient Hospice 20% coinsurance after 40% coinsurance after deductible is met deductible is met Durable Medical Equipment 20% coinsurance after 40% coinsurance after deductible is met deductible is met Prosthetic Devices 20% coinsurance after 40% coinsurance after deductible is met deductible is met Page 4of9 Notes: • If you have an office visit with your Primary Care Physician, Specialist or Urgent Care at an Outpatient Facility(e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under"Outpatient Facility Services". • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • Outpatient Facility tests and treatments are limited to$350 per admission for Non-Network Providers. Includes: Diagnostic Services; X-ray; Surgery; Rehabilitation; Habilitation; Cardiac Therapy; Surgery at Ambulatory Surgical Centers. • Coverage includes standard fertility preservation services as a basic healthcare service including but are not limited to, injections, cryopreservation and storage for both male and female members when a medically necessary treatment may cause iatrogenic infertility. Member cost share for fertility preservation services is based on provider type and service rendered. • The representations of benefits in this document are subject to California Department of Insurance (DOI) approval and are subject to change. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail. Anthem Blue Cross is the trade name of Blue Cross of California.Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association.®ANTHEM is a registered trademark of Anthem Insurance Companies,Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. Questions: (855) 333-5730 or visit us at www.anthem.com/ca Page 5 of 9 Your summary of benefits Anthem Ot Intentionally Left Blank Anthem® :.: Get help in your language BlueCross Notice of Language Assistance Curious to know what all this says? We would be too. Here's the English version: No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-888-254-2721. For more help call the CA Dept. of Insurance at 1-800-927-4357. (TTY/TDD: 711) Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. Spanish Servicios lingOfsticos sin costo. Puede tener un interprete. Puede solicitar que le lean los documentos y algunos puede recibirlos en su idioma. Para obtener ayuda, Ilamenos al nOmero que figura en su tarjeta de identificacion o al 1-888-254- 2721. Para obtener ayuda adicional, Ilame al Departamento de Seguros de California al 1-800-927-4357. (TTY/TDD: 711) Arabic c�sL�l J� .,Z' Jam=} J19 ul ll Ids`jL "9 .1-888-254-2721 1 a.oL�i y�]I Buz � 9.31 �yll L J.al (TTY/TDD: 711) .1-800-927-4357 JLaYI t_ ofi `yo J. Armenian Ruipgtfwti�w4t iti uitiijttwp 8uinuijntlalnttitihp: Uhtip 4uipnil htip Qhq puipgtfw'UAi buinwjntlalnttitihp WDW2uip4ht 11wpnil htip tnpwtfuiilphl jitiZ-np tfh4 h,nij tjiuiutntulaillahppi 44wpilui Qhq hurt wp h 4nLrjtup4 ilpwlip Qhp Itiggnq: OghntlalnLh utnu hwtnt hwtfwp gwhgwhwphp tfhq Qhq ID puipu*Ow tlAuib hhr2wjunuwhtutfuipnij 4wtf 1-888-254-2721 hwtfuipnij: 1-puignLgji oghntla wh htutfwp gwhquihwphp gtulji�nnhi wjji uiulwhnijtugpntlajtuti utujuuipwpntlajntti hhtntljwt hhnuijunuuihuitfwpnq 1-800-927-4357: (TTY/TDD: 711) Chinese An#li#7f�,M ID+-LMVtT,%°�t1-888-254-2721ryp-�-RTri ° z43E f m J 'Uj JP,IT1-800-927-4357 IyN�4-ACA Dept. of Insurance ° (TTY/TDD: 711) Farsi 5 I �-- I � J Lew I ,.U_m I �"�� ,Lt�I y_ir° • 'x--'�� L_°-"' ?-?)-'—° S� ..L-i�19--'r° •c�L-'j U L3�I � .�L�,A_i j l a Sa�S s�Lam) y J 3-w J Lw I j L-L-�Iy I T— L a ,L� j � . 1-888-254-2721 - _>Jc j I L� 9 0 L=,L,-_j Lw L; , _,) LS ) -,w j-+-3 o) L, .r, ,j_,�b a) L o_w d-j L�—ir I LS a_a_u o) I I L_r y,:� L5 LT n < C.L9 Lam) L5 I r< . L,I o`i La L� (TTY/TDD:711) . ., ,J , < : LaL_a`i 1-800-927-4357 Hindi f�W RTJTff Eft W T #M#1 3ffq PfN,14111 Afccf B+T FW;� tI 3ffq 2,TdI41,31 qdT W; t 3T ;WU 3ffgfft 3if9r-fr ww 7T uw ti � ,�V, �* 3fq* ID Wd qT 4 W4T qT zrT 1-888-254-2721 qT ch-ic4 B0I W fc!`V 1-800-927-4357 qT CA tW ft TT +`N W4I (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CD13 CDIW1 #CA-CDI-001 Page 7 of 9 Hmong Tsis Xam Tus Nqi Cov Kev Pab Cuam Ntsig Txog Horn Lus.Koj muaj peev xwm tau txais ib tus neeg txhais Ins.Koj muaj peev xwm tau txais cov ntaub ntawv nyeem ua koj horn Ins ran koj mloog thiab yuav xa ib co ntaub ntawv sau ua koj horn Ins tuaj ran koj. Txog ran kev pab,hu rau peb tus nab npawb xov tooj teev tseg cia nyob ran ntawm koj daim ID Ios sis 1-888-254-2721. Txog ran kev pab ntxiv, hu xov tooj ran Pab Kas Phais Lub Chaw Ua Hauj Lwm CA tus xov tooj 1-800-927-4357. (TTY/TDD: 711) Japanese �I .{,, T 21 {� L } T T'F FI PG / Exo ) GI\ �� XI��1V o *�t�F7 PG `�a�PLdT-L�-Yt_ I), 3ZW: I L"J�G ` o # xlf�lZl�, IDS— FI�a� It_; s, t-1 1-888-254-2721 IZ A1< t= Oo 5MOSo Oft, t 'J7�111.= 71lM4;T;,RP- (1-800-927-4357) IZ V Eon< t_;�LNo (TTY/TDD: 711) Khmer SNwnft14(tit111111 t9Hf94waatIf NUStftl 9lhldtifitllftlmtSt(Uettf{1lm8i1 tIftBlttUtl MM ID 1- 888-254-2721 q wmtrrivrtanoSai CA Dept. of Insurance muttue 1-800-927-4357i(TTY/TDD: 711) Korean T� 01 �idl� �°��Fz olo�Fz' T °1dLl�F. �I6F°I ao1� �o�lci �Foi�l L iz ��oF�a T AA �-z .—121 1 I D 5' `011 71 TH j1 di Q -L 1-888-254-2721 i= Li 4f o f d1��4. �h z �-c,:',0 1 z Q oF,k l T1 1-800-927-4357 ii -Y-o CA TAi ail o°I T d1�I4. (TTY/TDD: 711) Punjabi f>aF1 F rT3 c�3rFir�l 370 t7 c�Ir as ua;Ll-91 ;�t 3ut Lau;E�R-F Tae*9 yr3 7V 37t 3w f--tt 3 l�#rly Rc t}U61 7 e:E t3Et, 7-rt 3 l Y fT 7rav tm�7 BTU W 1-888-254-2721 751*zrrF Tll f:ram.-hfr2r 7 f�i-5t, Tt-a f:>a4-a�Oz�Yq'a f c�dOFF 25 1-800-927-4357�q F5 i5A (TTY/TDD: 711) Russian 6ecnnaTHble A3bIKOBbie ycnyrm. BbI moweTe nony4VlTb ycnyrm ycTHoro nepeBOgLIMKa. BaM MoryT npOLIWTaTb,gOKyMeHTbI mnm HanpaBNTb HeKOTOpbie m3 HNX Ha BaWeM 3q3bIKe. ,gnFi nony4eHNs1 nomol-41ol 31301-11/1Te Ham nO TeneC}OHy, yKa3aHHOMy Ha BaWeM m,4eHTmC�mKaumOHHON KapTe, mnm no HOMepy 1-888-254-2721. ,QnA nony4eHmA gononHMTenbHON nOM0611m 313OHNTe B ,genapTameHT cTpaxOBaHmsl wraTa KanmC} OpHms1 no HOmepy 1-800-927-4357. (TTY/TDD: 711) Tagalog Mga Libreng Serbisyo para sa Wika. Maaari kayong kumuha ng interpreter. Maaari ninyong ipabasa ang mga dokumento at ipadala ang ilan sa mga ito sa inyo sa wikang ginagamit ninyo. Para sa tulong, tawagan kami sa numerong nakalista sa inyong ID card o sa 1-888-254-2721. Para sa higit pang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357. (TTY/TDD: 711) Thai �8J8JG1'1115t1'156i'1fJatllJfl'll�'1 VI'111c�'18J'15€12Je�Z2i115t1'15�'15J�G1 l/I'111c�'15J'15€12Je�Z1'i6a'11'111'll%I�'1116e�tic�'15�G11/I'111�J66c�86e�tic�'159J'1Je�El'1�9a��Jt1JVl'111�G1EIZ2i31'll�'12Je�5Vllld �1lflGle�Jf1'15W1a15J2faE16Vi�e� �115G1�VISVil65lG1l5JVI5J 1EI6c�21V15811e7rJllutiG15115�a1G1`a�lavvi�ul�savi1�a11€16a21 1-888-254-2721 1��Giavrl�swla�al2faEI6VIaa61N8J6G15J 11I'YM1Y/I5OiMM-11J66G4un CA Dept. of Insurance 1!1MIFIOL&T 1-800-927-4357 (TTY/TDD: 711) Vietnamese Cac Dich Vu Ngon Ngur Mien Phi. Quy vi co the co thong dich vien. Quy vi co the yeu cau doc tai lieu cho quy vi nghe va yeu cau gul mot so tai lieu bang ngon ngur cua quy vi cho quy vi. De du°ac tra giup, hay goi cho so dtxac ghi tren the ID cua quy vi hoac so 1-888-254-2721. De dlxgc giup da them, hay goi cho Sd Bao Hiem California (California Department of Insurance)theo so 1-800-927-4357. (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CD13 CDIW1 #CA-CDI-001 Page 8 of 9 It's important we treat you fairly That's why we follow federal civil rights laws in our health programs and activities. We don't discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn't English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1-800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobby.osf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htmi. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CD13 CDIW1 #CA-CDI-001 Page 9 of 9 Your summary of benefits �mthem 0 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA) — County of Fresno: PPO (HSA) 3000 Your Network: Prudent Buyer PPO Visits with Virtual Care-Only Providers Cost through our mobile app and website Primary Care, and medical services for urgent/acute care No charge after deductible is met Mental Health &Substance Use Disorder Services No charge after deductible is met Specialist care No charge after deductible is met Cost if you use an In- Cost if you use a ProviderCovered Medical Benefits Network Provider Non-Network Overall Deductible $3,000 person / $3,000 person / $6,000 family $6,000 family Overall Out-of-Pocket Limit $3,000 person / $5,000 person / $6,000 family $10,000 family The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per person deductible and per person out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per person deductible or per person out-of-pocket limit. All medical and prescription drug deductibles, copayments and coinsurance apply to the out-of-pocket limit. In-Network and Non-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other. Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder No charge after 50% coinsurance after Services virtual and office deductible is met deductible is met Specialist Care virtual and office No charge after 50% coinsurance after deductible is met deductible is met Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) No charge after 50% coinsurance after deductible is met deductible is met Retail Health Clinic for routine care and treatment of common illnesses; No charge after 50% coinsurance after usually found in major pharmacies or retail stores. deductible is met deductible is met CA/LG/Anthem PPO (HSA) 3000/48B3/12-11-2023 Page 1 of 9 CoveredCost if you use an In- Cost if you use a Medical Provider Manipulation Therapy No charge after 50% coinsurance after Coverage is limited to 24 visits per benefit period. deductible is met deductible is met Acupuncture No charge after 50% coinsurance after Coverage is limited to 12 visits per benefit period. deductible is met deductible is met Other Services in an Office Allergy Testing No charge after 50% coinsurance after deductible is met deductible is met Prescription Drugs Dispensed in the office 30% coinsurance after 50% coinsurance after Maximum of$250 member cost share per drug. deductible is met deductible is met Surgery No charge after 50% coinsurance after deductible is met deductible is met Preventive care 1 screenings 1 immunizations No charge 50% coinsurance after deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge 50% coinsurance after deductible is met Diagnostic Services Lab Office No charge after 50% coinsurance after deductible is met deductible is met Freestanding Lab No charge after 50% coinsurance after deductible is met deductible is met Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible is met X-Ray Office No charge after 50% coinsurance after deductible is met deductible is met Freestanding Radiology Center No charge after 50% coinsurance after deductible is met deductible is met Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible is met Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office No charge after 50% coinsurance after deductible is met deductible is met Freestanding Radiology Center No charge after 50% coinsurance after deductible is met deductible is met Page 2 of 9 CoveredCost if you use an In- Cost if you use a Medical Provider j6L I Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible ismet Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply No charge after 50% coinsurance after depending on the care provided. deductible is met deductible is met Emergency Room Facility Services No charge after Covered as In-Network deductible is met Emergency Room Doctor and Other Services No charge after Covered as In-Network deductible is met Ambulance No charge after Covered as In-Network deductible is met Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees No charge after 50% coinsurance after deductible is met deductible is met Doctor Services No charge after 50% coinsurance after deductible is met deductible is met Outpatient Surgery Facility Fees Hospital No charge after 50% coinsurance after deductible is met deductible is met Ambulatory Surgical Center No charge after 50% coinsurance after deductible is met deductible is met Physician and other services including surgeon fees Hospital No charge after 50% coinsurance after deductible is met deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) Facility Fees No charge after 50% coinsurance after deductible is met deductible is met Physician and other services including surgeon fees No charge after 50% coinsurance after deductible is met deductible is met Home Health Care No charge after 50% coinsurance after Coverage is limited to 100 visits per benefit period. deductible is met deductible is met Page 3 of 9 i CoveredCost if you use an In- Cost if you use a Medical Provider Ak— Rehabilitation and Habilitation services including physical, occupational and speech therapies. Office No charge after 50% coinsurance after deductible is met deductible is met Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible is met Pulmonary rehabilitation office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met Cardiac rehabilitation office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met DialysislHemodialysis office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met ChemolRadiation Therapy office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met Skilled Nursing Care (facility) No charge after 50% coinsurance after Coverage is limited to 100 days per benefit period. deductible is met deductible is met Inpatient Hospice No charge after 50% coinsurance after deductible is met deductible is met Durable Medical Equipment No charge after 50% coinsurance after deductible is met deductible is met Prosthetic Devices No charge after 50% coinsurance after deductible is met deductible is met Page 4of9 Notes: • If you have an office visit with your Primary Care Physician, Specialist or Urgent Care at an Outpatient Facility(e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under"Outpatient Facility Services". • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • Outpatient Facility tests and treatments are limited to$350 per admission for Non-Network Providers. Includes: Diagnostic Services; X-ray; Surgery; Rehabilitation; Habilitation; Cardiac Therapy; Surgery at Ambulatory Surgical Centers. • Coverage includes standard fertility preservation services as a basic healthcare service including but are not limited to, injections, cryopreservation and storage for both male and female members when a medically necessary treatment may cause iatrogenic infertility. Member cost share for fertility preservation services is based on provider type and service rendered. • The representations of benefits in this document are subject to California Department of Insurance (DOI) approval and are subject to change. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail. Anthem Blue Cross is the trade name of Blue Cross of California.Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company arc independent licensees of the Blue Cross Association.®ANTHEM is a registered trademark of Anthem Insurance Companies,Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. Questions: (855) 333-5730 or visit us at www.anthem.com/ca Page 5 of 9 Your summary of benefits Anthem Ot Intentionally Left Blank Anthem® :.: Get help in your language BlueCross Notice of Language Assistance Curious to know what all this says? We would be too. Here's the English version: No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-888-254-2721. For more help call the CA Dept. of Insurance at 1-800-927-4357. (TTY/TDD: 711) Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. Spanish Servicios lingOfsticos sin costo. Puede tener un interprete. Puede solicitar que le lean los documentos y algunos puede recibirlos en su idioma. Para obtener ayuda, Ilamenos al nOmero que figura en su tarjeta de identificacion o al 1-888-254- 2721. Para obtener ayuda adicional, Ilame al Departamento de Seguros de California al 1-800-927-4357. (TTY/TDD: 711) Arabic c�sL�l J� .,Z' Jam=} J19 ul ll Ids`jL "9 .1-888-254-2721 1 a.oLill -4 41 a917. � 9.31 �yll 5� L J-al (TTY/TDD: 711) .1-800-927-4357 Lu)yiitS )I-, JLaYIy cb�ct_ oft `yo Jg _li Armenian Rurpgtfwti�tu4urtr urtrtlt wp 8urnurjntlalnttrtrhp: Uhhp 4wpnrl htrp Qhq laurpgtfw'UAi burnwjntlajnttrtrhp WDW2urp4ht 11wpnrl htrp tnpwtfwrlphl hhZ-np tfh4 h,nq Lj urutnwjarllahpp 44wprlur Qhq hurtfwp h 4ntgtup4 rlpwlrp Qhp Itiggnq: OghntlajnLh utnu hwtnt hwtfwp gwhgwhwphp tfhq Qhq ID purpu*Ow tlAurb hhr2wjunuwhtutfurpnq 4wtf 1-888-254-2721 hwtfurpnq: 1-purgntg� oghntla wh htutfwp gwhqurhwphp gtut� nntr�wju tuulwhngwgpntlajtutr utuluuipwpntlajnttr hhtntljwt hhnurjunuuihtutfwpnq 1-800-927-4357: (TTY/TDD: 711) Chinese An#li#7f�,M ID+-LMVtT,%°�t1-888-254-2721ryp-�-RTri ° z43E f m J 'Uj JP,IT1-800-927-4357 IyN�4-ACA Dept. of Insurance ° (TTY/TDD: 711) Farsi 5 I �-- I ) J Lew I ,.U_m I �"�� ,Lt�I y_ir° • 'x--'�� L_°-"' ?-?)-'-° S� ..L-i�19--'r° •c�L-'j U L3�I � .�L�,A_i j l a Sa�S s�Lam) y J 3-w J Lw) I j L-L-�Iy I T— L a ,L� j � . 1-888-254-2721 - _>Jc I L� 9 0 L=,L,-_j Lw L; , _,) LS ) -,w j-+-3 o) L, .r, ,g_,�b L�-ir I LS L5 LT n < C.L9 Lam)� �5 I � ��r< . L,I o`i La L� (TTY/TDD:711) . ., ,J , < : LaL_a`i 1-800-927-4357 Hindi f�W RTJTff Eft W T #M#1 3ffq PfN,1411 Afccf B+T FW;� tI 3ffq 2,TdI41,31 qdT W; t 3T ;WU 3ffgfft 3if9r-fr ww 7T uw ti � ,�V, �* 3fq* ID Wd qT 4 W4T qT zrT 1-888-254-2721 qT ch-ic4 B0I W fc!`V 1-800-927-4357 qT CA tW ft TT +`N W4I (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CD13 CDIW1 #CA-CDI-001 Page 7 of 9 Hmong Tsis Xam Tus Nqi Cov Kev Pab Cuam Ntsig Txog Horn Lus.Koj muaj peev xwm tau txais ib tus neeg txhais Ins.Koj muaj peev xwm tau txais cov ntaub ntawv nyeem ua koj horn Ins ran koj mloog thiab yuav xa ib co ntaub ntawv sau ua koj horn Ins tuaj ran koj. Txog ran kev pab,hu rau peb tus nab npawb xov tooj teev tseg cia nyob ran ntawm koj daim ID Ios sis 1-888-254-2721. Txog ran kev pab ntxiv, hu xov tooj ran Pab Kas Phais Lub Chaw Ua Hauj Lwm CA tus xov tooj 1-800-927-4357. (TTY/TDD: 711) Japanese �I .{,, T 21 {� L } T T'F FI PG / Exo ) GI\ �� XI��1V o *�t�F7 PG `�a�PLdT-L�-Yt_ I), 3ZW: I L"J�G ` o # xlf�lZl�, IDS— FI�a� It_; s, t-1 1-888-254-2721 IZ A1< t= Oo 5MOSo Oft, t 'J7�111.= 71lM4;T;,RP- (1-800-927-4357) IZ V Eon< t_;�LNo (TTY/TDD: 711) Khmer SNwnft14(tit111111 t9Hf94waatIf NUStftl 9lhldtifitllftlmtSt(Uettf{1lm8i1 tIftBlttUtl MM ID 1- 888-254-2721 q wmtrflq$tanoSal CA Dept. of Insurance muttue 1-800-927-4357i(TTY/TDD: 711) Korean T� 01 �idl� �°��Fz olo�Fz' T °1dLl�F. �I6F°I ao1� �o�lci �Foi�l L iz ��oF�a T AA �-z .—121 1 I D 5' `011 71 TH j1 di Q -L 1-888-254-2721 i= Li 4f o f d1��4. �h z �-c,:',0 1 z Q oF,k l T1 1-800-927-4357 ii -Y-o CA TAi ail o°I T d1�I4. (TTY/TDD: 711) Punjabi f>aF1 F rT3 c�3rFir�l 370 t7 c�Ir as ua;Ll-91 ;�t 3ut Lau;E�R-F Tae*9 yr3 7V 37t 3w f--tt 3 l�#rly Rc t}U61 7 e:E t3Et, 7-rt 3 l Y fT 7rav tm�7 BTU W 1-888-254-2721 751*zrrF Tll f:ram.-hfr2r 7 f�i-5t, Tt-a f:>a4-a�Oz�Yq'a f c�dOFF 25 1-800-927-4357�q F5 i5A (TTY/TDD: 711) Russian 6ecnnaTHble A3bIKOBbie ycnyrm. BbI moweTe nony4VlTb ycnyrm ycTHoro nepeBOgLIMKa. BaM MoryT npOLIWTaTb,gOKyMeHTbI mnm HanpaBNTb HeKOTOpbie m3 HNX Ha BaWeM 3q3bIKe. ,qnA nony4eHNA nOMOLum 31301-11/1Te Ham n0 TeneCpOHy, yKa3aHHOMy Ha BaWeM m,4eHTmC�mKaumOHHON KapTe, mnm n0 HOMepy 1-888-254-2721. ,QnA nony4eHMq,40nonHMTenbHON nOMOLum 3BOHNTe B ,genapTameHT cTpaxOBaHmsl WTaTa KanmC} OpHmsl no HOmepy 1-800-927-4357. (TTY/TDD: 711) Tagalog Mga Libreng Serbisyo para sa Wika. Maaari kayong kumuha ng interpreter. Maaari ninyong ipabasa ang mga dokumento at ipadala ang ilan sa mga ito sa inyo sa wikang ginagamit ninyo. Para sa tulong, tawagan kami sa numerong nakalista sa inyong ID card o sa 1-888-254-2721. Para sa higit pang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357. (TTY/TDD: 711) Thai �8J8JG1'1115t1'156f1fJatllJfl'll�'1 VI'111c�'18J'15€12Je�Z2i115t1'15�'15J�G1 l/I'111c'�'15J'15€121e��1'Y6a'11'111'll%I�'1116e�tic'�'15�G11/I'111�J66c�86e�tic'�'159J"1Je�EI'1�9a��JtIJVI'111�G1EIZ2i31'19�''121e��91/I'll! 1'1'1flGle�Jfl'15G1a15J2f7EI6Vi�e� �115G1�VISVil65lG1l5JVI5J 1EI6c�21V15811e7rJllutiG15115�a1G1`a�lavvi�ul�savil�al 1€16a21 1-888-254-2721 1��Giavrl�swla�al2faEI6VIaa61N8J6G15J 11I'YM1Y/I5OiMM-11J66G4un CA Dept. of Insurance 1!1MIFIOL&T 1-800-927-4357 (TTY/TDD: 711) Vietnamese Cac Dich Vu Ngon Ngur Mien Phi. Quy vi co the co thong dich vien. Quy vi co the yeu cau doc tai lieu cho quy vi nghe va yeu cau gul mot so tai lieu bang ngon ngur cua quy vi cho quy vi. De du°ac tra giup, hay goi cho so dLvac ghi tren the ID cua quy vi hoac so 1-888-254-2721. De dlxgc giup da them, hay goi cho Sd Bao Hiem California (California Department of Insurance)theo so 1-800-927-4357. (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CD13 CDIW1 #CA-CDI-001 Page 8 of 9 It's important we treat you fairly That's why we follow federal civil rights laws in our health programs and activities. We don't discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn't English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1-800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobbV.wsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htmi. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CD13 CDIW1 #CA-CDI-001 Page 9 of 9 Your summary of benefits �mthem 0 Anthem® Blue Cross Your Plan: San Joaquin Valley Insurance Authority (JPA) — County of Fresno: PPO HDHP 3000 Your Network: Prudent Buyer PPO Visits with Virtual Care-Only Providers Cost through our mobile app and website Primary Care, and medical services for urgent/acute care No charge after deductible is met Mental Health &Substance Use Disorder Services No charge after deductible is met Specialist care No charge after deductible is met Cost if you use an In- Cost if you use a ProviderCovered Medical Benefits Network Provider Non-Network Overall Deductible $3,000 person / $3,000 person / $6,000 family $6,000 family Overall Out-of-Pocket Limit $3,000 person / $5,000 person / $6,000 family $10,000 family The family deductible and out-of-pocket limit are embedded, meaning the cost shares of one family member will be applied to the per person deductible and per person out-of-pocket limit; in addition, amounts for all covered family members apply to both the family deductible and family out-of-pocket limit. No one member will pay more than the per person deductible or per person out-of-pocket limit. All medical and prescription drug deductibles, copayments and coinsurance apply to the out-of-pocket limit. In-Network and Non-Network deductibles and out-of-pocket limit amounts are separate and do not accumulate toward each other. Doctor Visits (virtual and office) You are encouraged to select a Primary Care Physician (PCP). Primary Care (PCP) and Mental Health and Substance Use Disorder No charge after 50% coinsurance after Services virtual and office deductible is met deductible is met Specialist Care virtual and office No charge after 50% coinsurance after deductible is met deductible is met Other Practitioner Visits Routine Maternity Care (Prenatal and Postnatal) No charge after 50% coinsurance after deductible is met deductible is met Retail Health Clinic for routine care and treatment of common illnesses; No charge after 50% coinsurance after usually found in major pharmacies or retail stores. deductible is met deductible is met CA/LG/Anthem PPO (HDHP) 3000/48B3/01-01-2024 Page 1 of 9 CoveredCost if you use an In- Cost if you use a Medical Provider Manipulation Therapy No charge after 50% coinsurance after Coverage is limited to 24 visits per benefit period. deductible is met deductible is met Acupuncture No charge after 50% coinsurance after Coverage is limited to 12 visits per benefit period. deductible is met deductible is met Other Services in an Office Allergy Testing No charge after 50% coinsurance after deductible is met deductible is met Prescription Drugs Dispensed in the office 30% coinsurance after 50% coinsurance after Maximum of$250 member cost share per drug. deductible is met deductible is met Surgery No charge after 50% coinsurance after deductible is met deductible is met Preventive care 1 screenings 1 immunizations No charge 50% coinsurance after deductible is met Preventive Care for Chronic Conditions per IRS guidelines No charge 50% coinsurance after deductible is met Diagnostic Services Lab Office No charge after 50% coinsurance after deductible is met deductible is met Freestanding Lab No charge after 50% coinsurance after deductible is met deductible is met Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible is met X-Ray Office No charge after 50% coinsurance after deductible is met deductible is met Freestanding Radiology Center No charge after 50% coinsurance after deductible is met deductible is met Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible is met Advanced Diagnostic Imaging for example: MRI, PET and CAT scans Office No charge after 50% coinsurance after deductible is met deductible is met Freestanding Radiology Center No charge after 50% coinsurance after deductible is met deductible is met Page 2 of 9 CoveredCost if you use an In- Cost if you use a Medical Provider j6L I Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible ismet Emergency and Urgent Care Urgent Care includes doctor services. Additional charges may apply No charge after 50% coinsurance after depending on the care provided. deductible is met deductible is met Emergency Room Facility Services No charge after Covered as In-Network deductible is met Emergency Room Doctor and Other Services No charge after Covered as In-Network deductible is met Ambulance No charge after Covered as In-Network deductible is met Outpatient Mental Health and Substance Use Disorder Services at a Facility Facility Fees No charge after 50% coinsurance after deductible is met deductible is met Doctor Services No charge after 50% coinsurance after deductible is met deductible is met Outpatient Surgery Facility Fees Hospital No charge after 50% coinsurance after deductible is met deductible is met Ambulatory Surgical Center No charge after 50% coinsurance after deductible is met deductible is met Physician and other services including surgeon fees Hospital No charge after 50% coinsurance after deductible is met deductible is met Hospital (Including Maternity, Mental Health and Substance Use Disorder Services) Facility Fees No charge after 50% coinsurance after deductible is met deductible is met Physician and other services including surgeon fees No charge after 50% coinsurance after deductible is met deductible is met Home Health Care No charge after 50% coinsurance after Coverage is limited to 100 visits per benefit period. deductible is met deductible is met Page 3 of 9 i CoveredCost if you use an In- Cost if you use a Medical Provider Ak— Rehabilitation and Habilitation services including physical, occupational and speech therapies. Office No charge after 50% coinsurance after deductible is met deductible is met Outpatient Hospital No charge after 50% coinsurance after deductible is met deductible is met Pulmonary rehabilitation office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met Cardiac rehabilitation office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met DialysislHemodialysis office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met ChemolRadiation Therapy office and outpatient hospital No charge after 50% coinsurance after deductible is met deductible is met Skilled Nursing Care (facility) No charge after 50% coinsurance after Coverage is limited to 100 days per benefit period. deductible is met deductible is met Inpatient Hospice No charge after 50% coinsurance after deductible is met deductible is met Durable Medical Equipment No charge after 50% coinsurance after deductible is met deductible is met Prosthetic Devices No charge after 50% coinsurance after deductible is met deductible is met Page 4of9 Notes: • If you have an office visit with your Primary Care Physician, Specialist or Urgent Care at an Outpatient Facility(e.g., Hospital or Ambulatory Surgical Facility), benefits for Covered Services will be paid under"Outpatient Facility Services". • Costs may vary by the site of service. Other cost shares may apply depending on services provided. Check your Certificate of Coverage for details. • The limits for physical, occupational, and speech therapy, if any apply to this plan, will not apply if you get care as part of the Mental Health and Substance Use Disorder benefit. • Outpatient Facility tests and treatments are limited to$350 per admission for Non-Network Providers. Includes: Diagnostic Services; X-ray; Surgery; Rehabilitation; Habilitation; Cardiac Therapy; Surgery at Ambulatory Surgical Centers. • Coverage includes standard fertility preservation services as a basic healthcare service including but are not limited to, injections, cryopreservation and storage for both male and female members when a medically necessary treatment may cause iatrogenic infertility. Member cost share for fertility preservation services is based on provider type and service rendered. • The representations of benefits in this document are subject to California Department of Insurance (DOI) approval and are subject to change. This summary of benefits is a brief outline of coverage, designed to help you with the selection process. This summary does not reflect each and every benefit, exclusion and limitation which may apply to the coverage. For more details, important limitations and exclusions, please review the formal Evidence of Coverage (EOC). If there is a difference between this summary and the Evidence of Coverage (EOC), the Evidence of Coverage (EOC), will prevail. Anthem Blue Cross is the trade name of Blue Cross of California.Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company arc independent licensees of the Blue Cross Association.®ANTHEM is a registered trademark of Anthem Insurance Companies,Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. Questions: (855) 333-5730 or visit us at www.anthem.com/ca Page 5 of 9 Your summary of benefits Anthem Ot Intentionally Left Blank Anthem® :.: Get help in your language BlueCross Notice of Language Assistance Curious to know what all this says? We would be too. Here's the English version: No Cost Language Services. You can get an interpreter. You can get documents read to you and some sent to you in your language. For help, call us at the number listed on your ID card or 1-888-254-2721. For more help call the CA Dept. of Insurance at 1-800-927-4357. (TTY/TDD: 711) Separate from our language assistance program, we make documents available in alternate formats for members with visual impairments. If you need a copy of this document in an alternate format, please call the customer service telephone number on the back of your ID card. Spanish Servicios lingOfsticos sin costo. Puede tener un interprete. Puede solicitar que le lean los documentos y algunos puede recibirlos en su idioma. Para obtener ayuda, Ilamenos al nOmero que figura en su tarjeta de identificacion o al 1-888-254- 2721. Para obtener ayuda adicional, Ilame al Departamento de Seguros de California al 1-800-927-4357. (TTY/TDD: 711) Arabic c�sL�l J� .,Z' Jam=} J19 ul ll Ids`jL "9 .1-888-254-2721 1 a.oLill -4 41 a917. � 9.31 �yll 5� L J-al (TTY/TDD: 711) .1-800-927-4357 Lu)yiitS )I-, JLaYIy cb�ct_ oft `yo Jg _li Armenian Rurpgtfwti�tu4urtr urtrtlt wp 8urnurjntlalnttrtrhp: Uhhp 4wpnrl htrp Qhq laurpgtfw'UAi burnwjntlajnttrtrhp WDW2urp4ht 11wpnrl htrp tnpwtfwrlphl hhZ-np tfh4 h,nq Lj urutnwjarllahpp 44wprlur Qhq hurtfwp h 4ntgtup4 rlpwlrp Qhp Itiggnq: OghntlajnLh utnu hwtnt hwtfwp gwhgwhwphp tfhq Qhq ID purpu*Ow tlAurb hhr2wjunuwhtutfurpnq 4wtf 1-888-254-2721 hwtfurpnq: 1-purgntg� oghntla wh htutfwp gwhqurhwphp gtut� nntr�wju tuulwhngwgpntlajtutr utuluuipwpntlajnttr hhtntljwt hhnurjunuuihtutfwpnq 1-800-927-4357: (TTY/TDD: 711) Chinese An#li#7f�,M ID+-LMVtT,%°�t1-888-254-2721ryp-�-RTri ° z43E f m J 'Uj JP,IT1-800-927-4357 IyN�4-ACA Dept. of Insurance ° (TTY/TDD: 711) Farsi 5 I �-- I ) J Lew I ,.U_m I �"�� ,Lt�I y_ir° • 'x--'�� L_°-"' ?-?)-'-° S� ..L-i�19--'r° •c�L-'j U L3�I � .�L�,A_i j l a Sa�S s�Lam) y J 3-w J Lw) I j L-L-�Iy I T— L a ,L� j � . 1-888-254-2721 - _>Jc I L� 9 0 L=,L,-_j Lw L; , _,) LS ) -,w j-+-3 o) L, .r, ,g_,�b L�-ir I LS L5 LT n < C.L9 Lam)� �5 I � ��r< . L,I o`i La L� (TTY/TDD:711) . ., ,J , < : LaL_a`i 1-800-927-4357 Hindi f�W RTJTff Eft W T #M#1 3ffq PfN,1411 Afccf B+T FW;� tI 3ffq 2,TdI41,31 qdT W; t 3T ;WU 3ffgfft 3if9r-fr ww 7T uw ti � ,�V, �* 3fq* ID Wd qT 4 W4T qT zrT 1-888-254-2721 qT ch-ic4 B0I W fc!`V 1-800-927-4357 qT CA tW ft TT +`N W4I (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CD13 CDIW1 #CA-CDI-001 Page 7 of 9 Hmong Tsis Xam Tus Nqi Cov Kev Pab Cuam Ntsig Txog Horn Lus.Koj muaj peev xwm tau txais ib tus neeg txhais Ins.Koj muaj peev xwm tau txais cov ntaub ntawv nyeem ua koj horn Ins ran koj mloog thiab yuav xa ib co ntaub ntawv sau ua koj horn Ins tuaj ran koj. Txog ran kev pab,hu rau peb tus nab npawb xov tooj teev tseg cia nyob ran ntawm koj daim ID Ios sis 1-888-254-2721. Txog ran kev pab ntxiv, hu xov tooj ran Pab Kas Phais Lub Chaw Ua Hauj Lwm CA tus xov tooj 1-800-927-4357. (TTY/TDD: 711) Japanese �I .{,, T 21 {� L } T T'F FI PG / Exo ) GI\ �� XI��1V o *�t�F7 PG `�a�PLdT-L�-Yt_ I), 3ZW: I L"J�G ` o # xlf�lZl�, IDS— FI�a� It_; s, t-1 1-888-254-2721 IZ A1< t= Oo 5MOSo Oft, t 'J7�111.= 71lM4;T;,RP- (1-800-927-4357) IZ V Eon< t_;�LNo (TTY/TDD: 711) Khmer SNwnft14(tit111111 t9Hf94waatIf NUStftl 9lhldtifitllftlmtSt(Uettf{1lm8i1 tIftBlttUtl MM ID 1- 888-254-2721 q wmtrflq$tanoSal CA Dept. of Insurance muttue 1-800-927-4357i(TTY/TDD: 711) Korean T� 01 �idl� �°��Fz olo�Fz' T °1dLl�F. �I6F°I ao1� �o�lci �Foi�l L iz ��oF�a T AA �-z .—121 1 I D 5' `011 71 TH j1 di Q -L 1-888-254-2721 i= Li 4f o f d1��4. �h z �-c,:',0 1 z Q oF,k l T1 1-800-927-4357 ii -Y-o CA TAi ail o°I T d1�I4. (TTY/TDD: 711) Punjabi f>aF1 F rT3 c�3rFir�l 370 t7 c�Ir as ua;Ll-91 ;�t 3ut Lau;E�R-F Tae*9 yr3 7V 37t 3w f--tt 3 l�#rly Rc t}U61 7 e:E t3Et, 7-rt 3 l Y fT 7rav tm�7 BTU W 1-888-254-2721 751*zrrF Tll f:ram.-hfr2r 7 f�i-5t, Tt-a f:>a4-a�Oz�Yq'a f c�dOFF 25 1-800-927-4357�q F5 i5A (TTY/TDD: 711) Russian 6ecnnaTHble A3bIKOBbie ycnyrm. BbI moweTe nony4VlTb ycnyrm ycTHoro nepeBOgLIMKa. BaM MoryT npOLIWTaTb,gOKyMeHTbI mnm HanpaBNTb HeKOTOpbie m3 HNX Ha BaWeM 3q3bIKe. ,qnA nony4eHNA nOMOLum 31301-11/1Te Ham n0 TeneCpOHy, yKa3aHHOMy Ha BaWeM m,4eHTmC�mKaumOHHON KapTe, mnm n0 HOMepy 1-888-254-2721. ,QnA nony4eHMq,40nonHMTenbHON nOMOLum 3BOHNTe B ,genapTameHT cTpaxOBaHmsl WTaTa KanmC} OpHmsl no HOmepy 1-800-927-4357. (TTY/TDD: 711) Tagalog Mga Libreng Serbisyo para sa Wika. Maaari kayong kumuha ng interpreter. Maaari ninyong ipabasa ang mga dokumento at ipadala ang ilan sa mga ito sa inyo sa wikang ginagamit ninyo. Para sa tulong, tawagan kami sa numerong nakalista sa inyong ID card o sa 1-888-254-2721. Para sa higit pang tulong, tawagan ang CA Dept. of Insurance sa 1-800-927-4357. (TTY/TDD: 711) Thai �8J8JG1'1115t1'156f1fJatllJfl'll�'1 VI'111c�'18J'15€12Je�Z2i115t1'15�'15J�G1 l/I'111c'�'15J'15€121e��1'Y6a'11'111'll%I�'1116e�tic'�'15�G11/I'111�J66c�86e�tic'�'159J"1Je�EI'1�9a��JtIJVI'111�G1EIZ2i31'19�''121e��91/I'll! 1'1'1flGle�Jfl'15G1a15J2f7EI6Vi�e� �115G1�VISVil65lG1l5JVI5J 1EI6c�21V15811e7rJllutiG15115�a1G1`a�lavvi�ul�savil�al 1€16a21 1-888-254-2721 1��Giavrl�swla�al2faEI6VIaa61N8J6G15J 11I'YM1Y/I5OiMM-11J66G4un CA Dept. of Insurance 1!1MIFIOL&T 1-800-927-4357 (TTY/TDD: 711) Vietnamese Cac Dich Vu Ngon Ngur Mien Phi. Quy vi co the co thong dich vien. Quy vi co the yeu cau doc tai lieu cho quy vi nghe va yeu cau gul mot so tai lieu bang ngon ngur cua quy vi cho quy vi. De du°ac tra giup, hay goi cho so dLvac ghi tren the ID cua quy vi hoac so 1-888-254-2721. De dlxgc giup da them, hay goi cho Sd Bao Hiem California (California Department of Insurance)theo so 1-800-927-4357. (TTY/TDD: 711) Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CD13 CDIW1 #CA-CDI-001 Page 8 of 9 It's important we treat you fairly That's why we follow federal civil rights laws in our health programs and activities. We don't discriminate, exclude people, or treat them differently on the basis of race, color, national origin, sex, age or disability. For people with disabilities, we offer free aids and services. For people whose primary language isn't English, we offer free language assistance services through interpreters and other written languages. Interested in these services? Call the Member Services number on your ID card for help (TTY/TDD: 711). If you think we failed to offer these services or discriminated based on race, color, national origin, age, disability, or sex, you can file a complaint, also known as a grievance. You can file a complaint with our Compliance Coordinator in writing to Compliance Coordinator, P.O. Box 27401, Mail Drop VA2002-N160, Richmond, VA 23279. Or you can file a complaint with the U.S. Department of Health and Human Services, Office for Civil Rights at 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201 or by calling 1-800-368-1019 (TDD: 1-800-537-7697) or online at https://ocrportal.hhs.gov/ocr/portal/lobbV.wsf. Complaint forms are available at http://www.hhs.gov/ocr/office/file/index.htmi. Anthem Blue Cross Life and Health Insurance Company is an independent licensee of the Blue Cross Association.ANTHEM is a registered trademark of Anthem Insurance Companies, Inc.The Blue Cross name and symbol are registered marks of the Blue Cross Association. MCASH4788CML 06/16 CD13 CDIW1 #CA-CDI-001 Page 9 of 9 Language Services: Spanish(Espanol):Para obtener asistencia en Espanol,Ilameal 1-877-241-7123. EmpiRx Tagalog(Tagalog):Kung kailangan ninyo ang tulong sa Tagalog tumawag sa EALTH 1-877-241-7123. Chinese (T X) III �F'XHJ '>31J> t� fiJ '1 1 i 1-877-241-7123. Navajo(Dine):Dinek'ehgo shika at'ohwol ninisingo,kwiijigo holne' 1-877-241-7123. SJVIA County of Fresno EPO PPO Plans Powered by iR HEALTH = Prescription Benefit Plan .V S J V I A San Joaquin Valley This brochure is only a general description of your prescription benefit program and is not Insurance Authority a contract.All benefits described herein are subject to the terms,conditions,and limitations of the group master contract and applicable law.All personal health information is kept strictly confidential,as required by the privacy rules of the Health Insurance Portability and Accountability Act. Logos are service marks of EmpiRx Health. EmpiRx Health Member Services CDPK.90.1800.000 1-87 Standard Brochure 1.2022 TDD:1-888-9 7 88-907-0020 24 hours a day, 7 days a week,365 days a year Your Prescription Benefit Program Specialty Medication Copay(Continued) Specialty medications can be filled one time at a retail pharmacy.After that,all prescriptions must be Annual Maximum Out of Pocket obtained through Benecard Central Fill specialty pharmacy.Please note that specialty medications are There is a$2,000 individual/$4,000 family maximum out of pocket. limited to a 30-day supply. Retail Pharmacy Copay Frequently Asked Questions You are responsible for paying the retail pharmacist the copay per prescription that is listed below: I How can I find a participating network pharmacy? 30-Day Supply 90-Day Supply You can use your EmpiRx Health ID card at over 63,000 pharmacies nationwide,including all pharmacy chains.You can locate a nearby network pharmacy by logging on to $10.00 for a Generic Medication $20.00 for a Generic Medication myempirxhealth.com or calling 1-877-262-7435 toll-free. I $20.00 for a Preferred Brand Medication $40.00 for a Preferred Brand Medication What is a clinical review,and why is it necessary? $35.00 for a Non-Preferred Brand $70.00 for a Non-Preferred Brand A clinical review of the request for medication is typically due to potential side effects,interactions, Medication Medication and FDA-guidelines.This is a safety measure to ensure you're getting the most appropriate treatment possible.EmpiRx Health will work directly with your physician to obtain the necessary This is a Dispense as Written(DAW)Plan,meaning your pharmacist must dispense the generic information before your prescription is filled.Once the review is complete,you'll be notified by mail, equivalent when one is available,unless your physician specifically requests the brand.If you request or via the online member portal.You can also check your status on the member portal any time at the brand-name medication from your pharmacist,you will be responsible for the difference in cost myempirxhealth.com. between the brand and the generic plus the copay. How can I find out if a particular prescription is covered by my benefits? Retail quantities will be dispensed according to your physician's instructions,as written on the You can check coverage easily by calling 1-877-262-7435 or logging onto myempirxheath.com for prescription,for up to a maximum of a 30-day supply or up to 100 units of a medication,whichever is details. greater. How can I find out if generic or lower-cost Please Note:If the cost of your medication is less than your calculated copay,you will only pay the cost alternatives may be available to me? Log onto the member portal myempirxhealth.com and select"Drug Pricing."Then search for your medication.If a of the medication. generic is available,you'll see the cost for both the brand and generic.You can also call 1-877-262-7435 or consult with your physician or pharmacist. Mail Service Pharmacy Copay Prescriptions for maintenance medications(medications you take on an ongoing basis)can be submitted Why does my copayment change from month to month? to Benecard Central Fill,the EmpiRx Health mail service pharmacy.Your plan allows for up to a 90-day We do not set the cost of medications.Pricing fluctuates based on market cost and may vary by pharmacy.If your supply with three(3)refills,according to your physician's instructions.Your copay amount will be: copay is based on a percentage,rather than a fixed dollar amount,the cost can be different depending on which pharmacy you use and the pricing of the medication at the time. 30-Day Supply 90-Day Supply I I $10.00 for a Generic Medication $15.00 for a Generic Medication $20.00 for a Preferred Brand Medication $30.00 for a Preferred Brand Medication $35.00 for a Non-Preferred Brand $60.00 for a Non-Preferred Brand Medication Medication Specialty Medication Copay Specialty medications are high-cost biotechnology drugs that require special distribution,handling,and administration.These medications are typically designed to treat chronic diseases.Your copay amount will be: $10.00 for a Generic Specialty Medication $20.00 for a Preferred Brand Specialty Medication $35.00 for a Non-Preferred Brand Specialty Medication Preferred Medication List Mail Order Pharmacy The preferred medication list serves as a guide to clinically and therapeutically-appropriate medications You can easily obtain your maintenance medications through the EmpiRx Health mail order covered under your plan.This does not take the place of your physician or pharmacist's judgment pharmacy,Benecard Central Fill.Typically,prescriptions filled through mail order are for regarding your individual needs.Refer to myempirxhealth.com to review the most recent preferred medications used to treat chronic conditions and are written for up to a 90-day supply,plus refills. medication list. You also have the option of obtaining 90-day supplies through the retail network.Prescriptions for medications that you need to use right away should always be taken to your local pharmacy. Exclusions For your first order,have your physician submit your prescription electronically to Benecard Your prescription program covers most medically necessary,federal legend,state-restricted,and Central Fill or fax it to 1-888-907-0040.Be sure that your physician includes the cardholder compounded medications,which by law may not be dispensed without a prescription. name,ID number,shipping address,and patient's date of birth.Only prescriptions sent directly from a doctor's office will be accepted via fax.To submit a prescription yourself,complete the Online Member Portal and Mobile App enclosed mail service order form and mail it,along with the original prescription,to Benecard Central Fill in the preaddressed envelope provided.To request additional mail order forms with Registration is easy.Along with your ID card,you will need basic member information,a phone number, preaddressed envelopes,please call 1-877-262-7435. and an email address.Log onto the member portal at myempirxhealth.com or download the app on Google Play or the App Store to access all your benefits information,including: Refill orders can be submitted online, by phone,or by mail. • Plan coverage details and copayment information Online:Visit myempirxhealth.com.If you have not yet registered,click on"Register."If • Network pharmacy finder you are a registered user,log in and select"Mail Order." • Mail order access to request refills and check order status By phone:Call Member Services toll-free at 1-877-262-7435,24 hours-a-day,7 days-a- • Updated preferred medication list week,365 days-a-year.Have your ID number and credit card information ready. • Drug comparison pricing tool to identify lower-cost alternatives • Drug information By mail:Send the refill request order form provided with your last shipment backto • Recent personal drug utilization history,including the amount you have paid and what the plan Benecard Central Fill in the preaddressed envelope. has paid on your behalf(this information is helpful for year-end tax purposes). Please note that EmpiRx Health does NOT automatically refill your prescriptions. Retail Pharmacy Network To avoid delays,always include the appropriate copay(if applicable)when your order is placed. Benecard Central Fill accepts Visa,MasterCard,Discover,American Express,and debit cards. Your EmpiRx Health prescription benefit provides access to an extensive national pharmacy You may also pay by check or money order made payable to Benecard Central Fill.Please do not network most chain pharmacies and most independents.Your plan allows for a 90-day supply send cash.Please allow up to two(2)weeks for delivery.Emergency prescriptions can be of maintenance medications.Your ID card provides all the information your pharmacist needs expedited at an additional charge. to process your prescription through EmpiRx Health.To locate a participating network pharmacy,log on to the member portal at myempirxhealth.com or call EmpiRx Health Member Services toll-free at 1-877-262-7435(TDD: 1-888-907-0020). Specialty Pharmacy Savings with Generic Medications Specialty pharmaceuticals are typically produced through biotechnology,administered by injection,or Generic equivalent drugs must meet the same Food and Drug Administration(FDA)standards for require special handling and patient monitoring. purity,strength,and safety as brand-name drugs.They must also have the same active ingredients and absorption rate within the body as the brand-name version,but they typically cost less.If you wish Through the specialty pharmacy,you receive personalized attention to help you manage your medical to take advantage of this savings opportunity,speak with your physician about the use of generics. condition,including one-on-one counseling with our team of pharmacists and trained medical You may also want to consult with your pharmacist regarding generic drug options that may be professionals. available to you. Our clinical team partners with you and your prescribing doctor to ensure you understand: ID Cards If your ID card is not handy and there is an emergency need for a prescription,call EmpiRx Health Member • How to manage your condition Services toll-free at 1-877-262-7435(TDD: 1-888-907-0020),and we will provide your pharmacist with the • What medications you have been prescribed information required to process your prescription. • How to take your medication • What lower-cost options may be available Direct Member Reimbursement • How to coordinate delivery of your medication If you must pay out of pocket for medication covered by your plan,submit a Direct Member • How to safely handle and store your medication Reimbursement Form.You can obtain a copy of the form online at myempirxhealth.com.In addition to the form,you will need to provide an itemized receipt showing the following details:the amount charged,prescription number,medication dispensed,manufacturer,dosage form,strength,quantity, Shipments will arrive in secure,temperature-controlled packaging(if necessary)and will include and date dispensed.Your pharmacist can assist you if you do not have a detailed receipt.Direct everything you need to take your medication.Because of the sensitive nature of specialty medications, reimbursement is based on your plan benefits,and the amount reimbursed may be significantly lower some packages may require a signature. than the retail price you paid.Always try to use a participating network pharmacy and present your ID Where Can I Ship My Medications? card to reduce any unnecessary out-of-pocket expenses. We offer the convenience you need.Your medication can be shipped directly to: • Your home • Your work • Your doctor's office • A location of your choice Specialty Medications and Manufacturer Programs Members requiring specialty medications may be eligible to manufacture programs which financially assist members in the purchase of the medication. Specialty drugs have the following key characteristics: • Need frequent dosage adjustments. • Cause more severe side effects than traditional drugs • Need special storage,handling and/or administration. • Have a narrow therapeutic range. • Require periodic laboratory or diagnostic testing. Members will never pay more than standard plan copay for specialty drugs.Not all specialty medications have an associated manufacturer programs. Manufacturer programs have maximum dollar limits and can change program details at any time. The maximum copay support resets at specific manufacturer's program dates(generally Jan 1 each year,possible rolling 12 months from enrollment). Unless stated otherwise,manufacturer's payments do not count toward the patient's deductible and or out-of-pocket maximum obligations. Language Services: Spanish(Espanol):Para obtener asistencia en Espanol,Ilameal 1-877-241-7123. Emp 1�X Tagalog(Tagalog):Kung kailangan ninyo ang tulong sa Tagalog tumawag sa EALT 1-877-241-7123. Chinese (T X) III q�X87 '�JJ> t� fiJ '1 1 i 1-877-241-7123. Navajo(Dine):Dinek'ehgo shika at'ohwol ninisingo,kwiijigo holne' 1-877-241-7123. SJVIA County of Fresno HDHP 1500 Plan Poftred by Prescription HEALTH Benefit Plan 400 SJV I A San Joaquin Valley This brochure is only a general description of your prescription benefit program and is not Insurance Authority a contract.All benefits described herein are subject to the terms,conditions,and limitations of the group master contract and applicable law.All personal health information is kept strictly confidential,as required by the privacy rules of the Health Insurance Portability and Accountability Act. Logos are service marks of EmpiRx Health. EmpiRx Health Member Services CDPK.90.1800.000 1-87 Standard Brochure 1.2022 TDD:1-888-9 7 88-907-0020 24 hours a day, 7 days a week,365 days a year Your Prescription Benefit Program Frequently Asked Questions Upfront Deductible and Annual Maximum Out of Pocket How can I find a participating network pharmacy? There is a$1,500 individual/$3,000 Family Deductible. You can use your EmpiRx Health ID card at over 63,000 pharmacies nationwide,including all There is a$3,000 individual/$5,000 family maximum out of pocket. pharmacy chains.You can locate a nearby network pharmacy by logging on to myempirxhealth.com or calling 1-877-262-7435 toll-free. Retail Pharmacy Copay You are responsible for paying the retail pharmacist the copay per prescription that is listed below: What Is a Clinical review,and why is it necessary? A clinical review of the request for medication is typically due to potential side effects,interactions, 20%for a Generic Medication and FDA-guidelines.This is a safety measure to ensure you're getting the most appropriate 20%for a Brand Medication treatment possible.EmpiRx Health will work directly with your physician to obtain the necessary information before your prescription is filled.Once the review is complete,you'll be notified by mail, or via the online member portal.You can also check your status on the member portal any time at This is a Dispense as Written(DAW)Plan,meaning your pharmacist must dispense the generic myempirxhealth.com. equivalent when one is available,unless your physician specifically requests the brand.If you request How can I find out if a particular prescription is covered by my benefits? the brand-name medication from your pharmacist,you will be responsible for the difference in cost between the brand and the generic plus the copay. You can check coverage easily by calling 1-877-262-7435 or logging onto myempirxheath.com for details. Retail quantities will be dispensed according to your physician's instructions,as written on the How can I find out if generic or lower-cost prescription,for up to a maximum of a 30-day supply or up to 100 units of a medication,whichever is alternatives may be available to me? greater. Log onto the member portal myempirxhealth.com and select"Drug Pricing."Then search for your medication.If a generic is available,you'll see the cost for both the brand and generic.You can also Please Note:If the cost of your medication is less than your calculated copay,you will only pay the cost call 1-877-262-7435 or consult with your physician or pharmacist. of the medicatition. Why does my copayment change from month to month? Mail Service Pharmacy Copay We do not set the cost of medications.Pricing fluctuates based on market cost and may vary by Prescriptions for maintenance medications(medications you take on an ongoing basis)can be submitted pharmacy.If your copay is based on a percentage,rather than a fixed dollar amount,the cost can be to Benecard Central Fill,the EmpiRx Health mail service pharmacy.Your plan allows for up to a 90-day different depending on which pharmacy you use and the pricing of the medication at the time. supply with three(3)refills,according to your physician's instructions.Your copay amount will be: 20%for a Generic Medication 20%for a Brand Medication Specialty Medication Copay Specialty medications are high-cost biotechnology drugs that require special distribution,handling,and administration.These medications are typically designed to treat chronic diseases.Your copay amount will be: 20%for a Generic Specialty Medication 20%for a Brand Specialty Medication Specialty medications can be filled one time at a retail pharmacy.After that,all prescriptions must be obtained through Benecard Central Fill specialty pharmacy.Please note that specialty medications are limited to a 30-day supply. Preferred Medication List Mail Order Pharmacy The preferred medication list serves as a guide to clinically and therapeutically-appropriate medications You can easily obtain your maintenance medications through the EmpiRx Health mail order covered under your plan.This does not take the place of your physician or pharmacist's judgment pharmacy,Benecard Central Fill.Typically,prescriptions filled through mail order are for regarding your individual needs.Refer to myempirxhealth.com to review the most recent preferred medications used to treat chronic conditions and are written for up to a 90-day supply,plus refills. medication list. You also have the option of obtaining 90-day supplies through the retail network.Prescriptions for medications that you need to use right away should always be taken to your local pharmacy. Exclusions For your first order,have your physician submit your prescription electronically to Benecard Your prescription program covers most medically necessary,federal legend,state-restricted,and Central Fill or fax it to 1-888-907-0040.Be sure that your physician includes the cardholder compounded medications,which by law may not be dispensed without a prescription. name,ID number,shipping address,and patient's date of birth.Only prescriptions sent directly from a doctor's office will be accepted via fax.To submit a prescription yourself,complete the enclosed mail service order form and mail it,along with the original prescription,to Benecard Online Member Portal and Mobile App Central Fill in the preaddressed envelope provided.To request additional mail order forms with preaddressed envelopes,please call 1-877-262-7435. Registration is easy.Along with your ID card,you will need basic member information,a phone number, and an email address.Log onto the member portal at myempirxhealth.com or download the app on Refill orders can be submitted online, by phone,or by mail. Google Play or the App Store to access all your benefits information,including: • Online:Visit myempirxhealth.com.If you have not yet registered,click on"Register."If • Plan coverage details and copayment information you are a registered user,log in and select"Mail Order." • Network pharmacy finder By phone:Call Member Services toll-free at 1-877-262-7435,24 hours-a-day,7 days-a- • Mail order access to request refills and check order status week,365 days-a-year.Have your ID number and credit card information ready. • Updated preferred medication list • Drug comparison pricing tool to identify lower-cost alternatives By mail:Send the refill request order form provided with your last shipment backto • Benecard Central Fill in the preaddressed envelope. Drug information • Recent personal drug utilization history,including the amount you have paid and what the plan has paid on your behalf(this information is helpful for year-end tax purposes). Please note that EmpiRx Health does NOT automatically refill your prescriptions. To avoid delays,always include the appropriate copay(if applicable)when your order is placed. Retail Pharmacy Network Benecard Central Fill accepts Visa,MasterCard,Discover,American Express,and debit cards. You may also pay by check or money order made payable to Benecard Central Fill.Please do not Your EmpiRx Health prescription benefit provides access to an extensive national pharmacy send cash.Please allow up to two(2)weeks for delivery.Emergency prescriptions can be network most chain pharmacies and most independents.Your plan allows for a 90-day supply expedited at an additional charge. of maintenance medications.Your ID card provides all the information your pharmacist needs to process your prescription through EmpiRx Health.To locate a participating network pharmacy,log on to the member portal at myempirxhealth.com or call EmpiRx Health Member Services toll-free at 1-877-262-7435(TDD: 1-888-907-0020). Specialty Pharmacy Savings with Generic Medications Specialty pharmaceuticals are typically produced through biotechnology,administered by injection,or Generic equivalent drugs must meet the same Food and Drug Administration(FDA)standards for require special handling and patient monitoring. purity,strength,and safety as brand-name drugs.They must also have the same active ingredients and absorption rate within the body as the brand-name version,but they typically cost less.If you wish Through the specialty pharmacy,you receive personalized attention to help you manage your medical to take advantage of this savings opportunity,speak with your physician about the use of generics. condition,including one-on-one counseling with our team of pharmacists and trained medical You may also want to consult with your pharmacist regarding generic drug options that may be professionals. available to you. Our clinical team partners with you and your prescribing doctor to ensure you understand: ID Cards If your ID card is not handy and there is an emergency need for a prescription,call EmpiRx Health Member • How to manage your condition Services toll-free at 1-877-262-7435(TDD: 1-888-907-0020),and we will provide your pharmacist with the • What medications you have been prescribed information required to process your prescription. • How to take your medication • What lower-cost options may be available Direct Member Reimbursement • How to coordinate delivery of your medication • How to safely handle and store your medication If you must pay out of pocket for medication covered by your plan,submit a Direct Member Reimbursement Form.You can obtain a copy of the form online at myempirxhealth.com.In addition to the form,you will need to provide an itemized receipt showing the following details:the amount Shipments will arrive in secure,temperature-controlled packaging(if necessary)and will include charged,prescription number,medication dispensed,manufacturer,dosage form,strength,quantity, everything you need to take your medication.Because of the sensitive nature of specialty medications, and date dispensed.Your pharmacist can assist you if you do not have a detailed receipt.Direct some packages may require a signature. reimbursement is based on your plan benefits,and the amount reimbursed may be significantly lower than the retail price you paid.Always try to use a participating network pharmacy and present your ID Where Can I Ship My Medications? card to reduce any unnecessary out-of-pocket expenses. We offer the convenience you need.Your medication can be shipped directly to: • Your home • Your work • Your doctor's office • A location of your choice Specialty Medications and Manufacturer Programs Members requiring specialty medications may be eligible to manufacture programs which financially assist members in the purchase of the medication. Specialty drugs have the following key characteristics: • Need frequent dosage adjustments. • Cause more severe side effects than traditional drugs • Need special storage,handling and/or administration. • Have a narrow therapeutic range. • Require periodic laboratory or diagnostic testing. Members will never pay more than standard plan copay for specialty drugs.Not all specialty medications have an associated manufacturer programs. Manufacturer programs have maximum dollar limits and can change program details at any time. The maximum copay support resets at specific manufacturer's program dates(generally Jan 1 each year,possible rolling 12 months from enrollment). Unless stated otherwise,manufacturer's payments do not count toward the patient's deductible and or out-of-pocket maximum obligations. Language Services: Spanish(Espanol):Para obtener asistencia en Espanol,Ilameal 1-877-241-7123. EmPIRx, Tagalog(Tagalog):Kung kailangan ninyo ang tulong sa Tagalog tumawag sa EALTH 1-877-241-7123. Chinese (T X) III q�X87 '�JJ> t� fiJ '1 1 i 1-877-241-7123. Navajo(Dine):Dinek'ehgo shika at'ohwol ninisingo,kwiijigo holne' 1-877-241-7123. SJVIA County of Fresno HDHP 3000 Plans 1 mpiRx- i��> ��EALTH = Prescription Benefit Plan 400 SJ V I A San Joaquin Valley This brochure is only a general description of your prescription benefit program and is not Insurance Authority a contract.All benefits described herein are subject to the terms,conditions,and limitations of the group master contract and applicable law.All personal health information is kept strictly confidential,as required by the privacy rules of the Health Insurance Portability and Accountability Act. Logos are service marks of EmpiRx Health. EmpiRx Health Member Services CDPK.90.1800.000 1-87 Standard Brochure 1.2022 TDD:1-888-9 7 88-907-0020 24 hours a day, 7 days a week,365 days a year Your Prescription Benefit Program Frequently Asked Questions Upfront Deductible and Annual Maximum Out of Pocket How can I find a participating network pharmacy? There is a$3,000 individual/$6,000 Family Deductible. You can use your EmpiRx Health ID card at over 63,000 pharmacies nationwide,including all There is a$3,000 individual/$6,000 family maximum out of pocket. pharmacy chains.You can locate a nearby network pharmacy by logging on to myempirxhealth.com or calling 1-877-262-7435 toll-free. Retail Pharmacy Copay You are responsible for paying the retail pharmacist the copay per prescription that is listed below: What IS a Clinical review,and why is it necessary? A clinical review of the request for medication is typically due to potential side effects,interactions, $0 for a Generic Medication and FDA-guidelines.This is a safety measure to ensure you're getting the most appropriate $0 for a Brand Medication treatment possible.EmpiRx Health will work directly with your physician to obtain the necessary information before your prescription is filled.Once the review is complete,you'll be notified by mail, or via the online member portal.You can also check your status on the member portal any time at This is a Dispense as Written(DAW)Plan,meaning your pharmacist must dispense the generic myempirxhealth.com. equivalent when one is available,unless your physician specifically requests the brand.If you request How can I find out if a particular prescription is covered by my benefits? the brand-name medication from your pharmacist,you will be responsible for the difference in cost between the brand and the generic plus the copay. You can check coverage easily by calling 1-877-262-7435 or logging onto myempirxheath.com for details. Retail quantities will be dispensed according to your physician's instructions,as written on the How can I find out if generic or lower-cost prescription,for up to a maximum of a 30-day supply or up to 100 units of a medication,whichever is alternatives may be available to me? greater. Log onto the member portal myempirxhealth.com and select"Drug Pricing."Then search for your medication.If a generic is available,you'll see the cost for both the brand and generic.You can also Please Note:If the cost of your medication is less than your calculated copay,you will only pay the cost call 1-877-262-7435 or consult with your physician or pharmacist. of the medicatition. Why does my copayment change from month to month? Mail Service Pharmacy Copay We do not set the cost of medications.Pricing fluctuates based on market cost and may vary by Prescriptions for maintenance medications(medications you take on an ongoing basis)can be submitted pharmacy.If your copay is based on a percentage,rather than a fixed dollar amount,the cost can be to Benecard Central Fill,the EmpiRx Health mail service pharmacy.Your plan allows for up to a 90-day different depending on which pharmacy you use and the pricing of the medication at the time. supply with three(3)refills,according to your physician's instructions.Your copay amount will be: $0 for a Generic Medication $0 for a Brand Medication Specialty Medication Copay Specialty medications are high-cost biotechnology drugs that require special distribution,handling,and administration.These medications are typically designed to treat chronic diseases.Your copay amount will be: $0 for a Generic Specialty Medication $0 for a Brand Specialty Medication Specialty medications can be filled one time at a retail pharmacy.After that,all prescriptions must be obtained through Benecard Central Fill specialty pharmacy.Please note that specialty medications are limited to a 30-day supply. Preferred Medication List Mail Order Pharmacy The preferred medication list serves as a guide to clinically and therapeutically-appropriate medications You can easily obtain your maintenance medications through the EmpiRx Health mail order covered under your plan.This does not take the place of your physician or pharmacist's judgment pharmacy,Benecard Central Fill.Typically,prescriptions filled through mail order are for regarding your individual needs.Refer to myempirxhealth.com to review the most recent preferred medications used to treat chronic conditions and are written for up to a 90-day supply,plus refills. medication list. You also have the option of obtaining 90-day supplies through the retail network.Prescriptions for medications that you need to use right away should always be taken to your local pharmacy. Exclusions For your first order,have your physician submit your prescription electronically to Benecard Your prescription program covers most medically necessary,federal legend,state-restricted,and Central Fill or fax it to 1-888-907-0040.Be sure that your physician includes the cardholder compounded medications,which by law may not be dispensed without a prescription. name,ID number,shipping address,and patient's date of birth.Only prescriptions sent directly from a doctor's office will be accepted via fax.To submit a prescription yourself,complete the enclosed mail service order form and mail it,along with the original prescription,to Benecard Online Member Portal and Mobile App Central Fill in the preaddressed envelope provided.To request additional mail order forms with preaddressed envelopes,please call 1-877-262-7435. Registration is easy.Along with your ID card,you will need basic member information,a phone number, and an email address.Log onto the member portal at myempirxhealth.com or download the app on Refill orders can be submitted online, by phone,or by mail. Google Play or the App Store to access all your benefits information,including: • Online:Visit myempirxhealth.com.If you have not yet registered,click on"Register."If • Plan coverage details and copayment information you are a registered user,log in and select"Mail Order." • Network pharmacy finder By phone:Call Member Services toll-free at 1-877-262-7435,24 hours-a-day,7 days-a- • Mail order access to request refills and check order status week,365 days-a-year.Have your ID number and credit card information ready. • Updated preferred medication list • Drug comparison pricing tool to identify lower-cost alternatives By mail:Send the refill request order form provided with your last shipment backto • Benecard Central Fill in the preaddressed envelope. Drug information • Recent personal drug utilization history,including the amount you have paid and what the plan has paid on your behalf(this information is helpful for year-end tax purposes). Please note that EmpiRx Health does NOT automatically refill your prescriptions. To avoid delays,always include the appropriate copay(if applicable)when your order is placed. Retail Pharmacy Network Benecard Central Fill accepts Visa,MasterCard,Discover,American Express,and debit cards. You may also pay by check or money order made payable to Benecard Central Fill.Please do not Your EmpiRx Health prescription benefit provides access to an extensive national pharmacy send cash.Please allow up to two(2)weeks for delivery.Emergency prescriptions can be network most chain pharmacies and most independents.Your plan allows for a 90-day supply expedited at an additional charge. of maintenance medications.Your ID card provides all the information your pharmacist needs to process your prescription through EmpiRx Health.To locate a participating network pharmacy,log on to the member portal at myempirxhealth.com or call EmpiRx Health Member Services toll-free at 1-877-262-7435(TDD: 1-888-907-0020). Specialty Pharmacy Savings with Generic Medications Specialty pharmaceuticals are typically produced through biotechnology,administered by injection,or Generic equivalent drugs must meet the same Food and Drug Administration(FDA)standards for require special handling and patient monitoring. purity,strength,and safety as brand-name drugs.They must also have the same active ingredients and absorption rate within the body as the brand-name version,but they typically cost less.If you wish Through the specialty pharmacy,you receive personalized attention to help you manage your medical to take advantage of this savings opportunity,speak with your physician about the use of generics. condition,including one-on-one counseling with our team of pharmacists and trained medical You may also want to consult with your pharmacist regarding generic drug options that may be professionals. available to you. Our clinical team partners with you and your prescribing doctor to ensure you understand: ID Cards If your ID card is not handy and there is an emergency need for a prescription,call EmpiRx Health Member • How to manage your condition Services toll-free at 1-877-262-7435(TDD: 1-888-907-0020),and we will provide your pharmacist with the • What medications you have been prescribed information required to process your prescription. • How to take your medication • What lower-cost options may be available Direct Member Reimbursement • How to coordinate delivery of your medication • How to safely handle and store your medication If you must pay out of pocket for medication covered by your plan,submit a Direct Member Reimbursement Form.You can obtain a copy of the form online at myempirxhealth.com.In addition to the form,you will need to provide an itemized receipt showing the following details:the amount Shipments will arrive in secure,temperature-controlled packaging(if necessary)and will include charged,prescription number,medication dispensed,manufacturer,dosage form,strength,quantity, everything you need to take your medication.Because of the sensitive nature of specialty medications, and date dispensed.Your pharmacist can assist you if you do not have a detailed receipt.Direct some packages may require a signature. reimbursement is based on your plan benefits,and the amount reimbursed may be significantly lower than the retail price you paid.Always try to use a participating network pharmacy and present your ID Where Can I Ship My Medications? card to reduce any unnecessary out-of-pocket expenses. We offer the convenience you need.Your medication can be shipped directly to: • Your home • Your work • Your doctor's office • A location of your choice Specialty Medications and Manufacturer Programs Members requiring specialty medications may be eligible to manufacture programs which financially assist members in the purchase of the medication. Specialty drugs have the following key characteristics: • Need frequent dosage adjustments. • Cause more severe side effects than traditional drugs • Need special storage,handling and/or administration. • Have a narrow therapeutic range. • Require periodic laboratory or diagnostic testing. Members will never pay more than standard plan copay for specialty drugs.Not all specialty medications have an associated manufacturer programs. Manufacturer programs have maximum dollar limits and can change program details at any time. The maximum copay support resets at specific manufacturer's program dates(generally Jan 1 each year,possible rolling 12 months from enrollment). Unless stated otherwise,manufacturer's payments do not count toward the patient's deductible and or out-of-pocket maximum obligations. Disclosure Form Part One County of Fresno Group ID 580 - DHMO HSA Low PI Member Services 1-800-464-4000 Home Region: Northern California 12/11/23 through 12/8/24 Principal benefits for Kaiser Permanente HSA-Qualified High Deductible Health Plan ("HDHP") HMO "Kaiser Permanente HSA-Qualified High Deductible Health Plan ("HDHP") HMO" is a health benefit plan that meets the requirements of Section 223(c)(2)of the Internal Revenue Code. For a complete explanation, please refer to the EOC. Health Plan believes this coverage is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. If you have questions about grandfathered health plans, please call Member Services. Accumulation Period The Accumulation Period for this plan is January 1 through December 31. Out-of-Pocket Maximums and Deductibles For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. For Services that are subject to the Plan Deductible or the Drug Deductible, you must pay Charges for covered Services you receive during the Accumulation Period until you reach the deductible amounts listed below. All payments you make toward your deductibles apply to the Plan Out-of-Pocket Maximum amounts listed below. Self-Only Coverage Family Coverage Family Coverage Amounts Per Accumulation Period (a Family of one Member) Each Member in a Family Entire Family of two or of two or more Members more Members Plan Out-of-Pocket Maximum $3,000 $3,000 $6,000 Plan Deductible $3,000 $3,000 $6,000 Drug Deductible Not applicable Not applicable Not applicable Plan Provider Office Visits You Pay Most Primary Care Visits and most Non-Physician Specialist Visits...... No charge after Plan Deductible Most Physician Specialist Visits............................................................. No charge after Plan Deductible Routine physical maintenance exams, including well-woman exams.... No charge (Plan Deductible doesn't apply) Well-child preventive exams (through age 23 months).......................... No charge (Plan Deductible doesn't apply) Scheduled prenatal care exams............................................................. No charge (Plan Deductible doesn't apply) Routine eye exams with a Plan Optometrist.......................................... No charge (Plan Deductible doesn't apply) Urgent care consultations, evaluations, and treatment.......................... No charge after Plan Deductible Most physical, occupational, and speech therapy.................................. No charge after Plan Deductible Telehealth Visits You Pay Primary Care Visits and Non-Physician Specialist Visits by interactive video....................................................................................................... No charge after Plan Deductible Physician Specialist Visits by interactive video...................................... No charge after Plan Deductible Primary Care Visits and Non-Physician Specialist Visits by telephone.. No charge after Plan Deductible Physician Specialist Visits by telephone ................................................ No charge after Plan Deductible Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures.................. No charge after Plan Deductible Most immunizations (including the vaccine)........................................... No charge (Plan Deductible doesn't apply) Most X-rays and laboratory tests............................................................ No charge after Plan Deductible Preventive X-rays, screenings, and laboratory tests as described in the EOC................................................................................................ No charge (Plan Deductible doesn't apply) Hospitalization Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs..................................................................................................... No charge after Plan Deductible Emergency Health Coverage You Pay Emergency Department visits ................................................................ No charge after Plan Deductible Note: If you are admitted directly to the hospital as an inpatient for covered Services, you will pay the inpatient Cost Share instead of the Emergency Department Cost Share (see "Hospitalization Services"for inpatient Cost Share) Ambulance Services You Pay Ambulance Services............................................................................... No charge after Plan Deductible (continues) Disclosure Form Part One (continued) Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items (Tier 1) at a Plan Pharmacy or through our mail- No charge for up to a 100-day supply after Plan order service....................................................................................... Deductible Most brand-name items (Tier 2) at a Plan Pharmacy or through our No charge for up to a 100-day supply after Plan mail-order service............................................................................... Deductible Most specialty items (Tier 4)at a Plan Pharmacy............................... No charge for up to a 30-day supply after Plan Deductible Durable Medical Equipment (DME) You Pay Base DME items as described in the EOC............................................. No charge after Plan Deductible Supplemental DME items up to a $2,500 benefit limit per Accumulation Period as described in the EOC..................................... No charge after Plan Deductible Mental Health Services You Pay Inpatient psychiatric hospitalization........................................................ No charge after Plan Deductible Individual outpatient mental health evaluation and treatment................ No charge after Plan Deductible Group outpatient mental health treatment.............................................. No charge after Plan Deductible Substance Use Disorder Treatment You Pay Inpatient detoxification............................................................................ No charge after Plan Deductible Individual outpatient substance use disorder evaluation and treatment No charge after Plan Deductible Group outpatient substance use disorder treatment.............................. No charge after Plan Deductible Home Health Services You Pay Home health care (up to 100 visits per Accumulation Period) ............... No charge after Plan Deductible Other You Pay Eyeglasses or contact lenses: Eyeglass frame every 24 months........................................................ Amount in excess of$200 Allowance (Allowance not subject to Plan Deductible) Regular eyeglass lenses every 12 months.......................................... No charge (Plan Deductible doesn't apply) Contact lenses every 12 months......................................................... Amount in excess of$200 Allowance (Allowance not subject to Plan Deductible) Skilled nursing facility care (up to 100 days per benefit period)............. No charge after Plan Deductible Prosthetic and orthotic devices as described in the EOC...................... No charge after Plan Deductible Diagnosis and treatment of infertility and artificial insemination............. Not covered Assisted reproductive technology ("ART") Services............................... Not covered Hospice care .......................................................................................... No charge after Plan Deductible This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of- pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies). 8963.160.2.S000716455 embedded Disclosure Form Part One County of Fresno Group ID 580 - HMO Plan Member Services 1-800-464-4000 Home Region: Northern California 01/01/2024 through 12/31/2024 Principal benefits for Kaiser Permanente Traditional HMO Plan Health Plan believes this coverage is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. If you have questions about grandfathered health plans, please call Member Services. Accumulation Period The Accumulation Period for this plan is January 1 through December 31. Out-of-Pocket Maximums and Deductibles For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. Self-Only Coverage Family Coverage Family Coverage Amounts Per Accumulation Period (a Family of one Member) Each Member in a Family Entire Family of two or of two or more Members more Members Plan Out-of-Pocket Maximum $1,000 $1,000 $2,000 Plan Deductible None None None Drug Deductible None None None Plan Provider Office Visits You Pay Most Primary Care Visits and most Non-Physician Specialist Visits...... $15 per visit Most Physician Specialist Visits............................................................. $15 per visit Routine physical maintenance exams, including well-woman exams.... No charge Well-child preventive exams (through age 23 months).......................... No charge Scheduled prenatal care exams............................................................. No charge Routine eye exams with a Plan Optometrist.......................................... No charge Urgent care consultations, evaluations, and treatment.......................... $15 per visit Most physical, occupational, and speech therapy.................................. $15 per visit Telehealth Visits You Pay Primary Care Visits and Non-Physician Specialist Visits by interactive video....................................................................................................... No charge Physician Specialist Visits by interactive video...................................... No charge Primary Care Visits and Non-Physician Specialist Visits by telephone.. No charge Physician Specialist Visits by telephone ................................................ No charge Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures.................. $15 per procedure Most immunizations (including the vaccine)........................................... No charge Most X-rays and laboratory tests............................................................ No charge Hospitalization Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs..................................................................................................... No charge Emergency Health Coverage You Pay Emergency Department visits ................................................................ $100 per visit Note: If you are admitted directly to the hospital as an inpatient for covered Services, you will pay the inpatient Cost Share instead of the Emergency Department Cost Share (see "Hospitalization Services"for inpatient Cost Share) Ambulance Services You Pay Ambulance Services............................................................................... No charge Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items (Tier 1) at a Plan Pharmacy................................. $10 for up to a 30-day supply Most generic (Tier 1) refills through our mail-order service................. $20 for up to a 100-day supply Most brand-name items (Tier 2) at a Plan Pharmacy.......................... $20 for up to a 30-day supply Most brand-name (Tier 2) refills through our mail-order service ......... $40 for up to a 100-day supply Most specialty items (Tier 4)at a Plan Pharmacy............................... $20 for up to a 30-day supply Durable Medical Equipment (DME) You Pay DME items as described in the EOC...................................................... No charge (continues) Disclosure Form Part One (continued) Mental Health Services You Pay Inpatient psychiatric hospitalization........................................................ No charge Individual outpatient mental health evaluation and treatment................ $15 per visit Group outpatient mental health treatment.............................................. $7 per visit Substance Use Disorder Treatment You Pay Inpatient detoxification............................................................................ No charge Individual outpatient substance use disorder evaluation and treatment $15 per visit Group outpatient substance use disorder treatment.............................. $5 per visit Home Health Services You Pay Home health care (up to 100 visits per Accumulation Period)............... No charge Other You Pay Eyeglasses or contact lenses: Eyeglass frame every 24 months........................................................ Amount in excess of$200 Allowance Regular eyeglass lenses every 12 months.......................................... No charge Contact lenses every 12 months......................................................... Amount in excess of$200 Allowance Hearing aids every 36 months................................................................ Amount in excess of$1,000 Allowance per aid Skilled nursing facility care (up to 100 days per benefit period)............. No charge Prosthetic and orthotic devices as described in the EOC...................... No charge Services to diagnose or treat infertility and artificial insemination (such as outpatient procedures or laboratory tests) as described in the the Cost Share you would pay if the Services were EOC...................................................................................................... to treat any other condition Assisted reproductive technology ("ART') Services............................... Not covered Hospice care .......................................................................................... No charge This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of- pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies). 8963.155.1.S000713336 Provided by American Specialty Health Plans of California, Inc. (ASH Plans) Your Kaiser Permanente CHIROPRACTIC When you need chiropractic care,follow these simple steps: 1. Find an ASH Participating Provider near you: • Go to ashlink.com/ash/kp, or • Call 1-800-678-9133 (TT ' 711), Monday through Friday, from 5 a.m.to 6 p.m. Pacific time 2. Schedule an appointment. 3. Pay for your office visit when you arrive for your appointment. (See the reverse for more details_) Amman SpecalryHealth KAISER PERMANENTE. f)fills(ll 1, IIIIIII YOUR KAISER PERMANENTE CHIROPRACTIC BENEFIT Office Visits Cost Sharing and Visit Limits Covered Sen-xes are limited to-V_edically Necessary Chiropractic Office vmt cost hare:S H copymew per visit(if your Amer l"i rz Services authorized and Frovided be ASH Pancipat>ce Providers eve_:' is paired with at HDHP fiM0 a-dence of coverage,dLs cost share:s for the iritia:etacunanorr Emergency Chugrxix Services.Urgent slbiect to the Zan Dedu:rb:e described in your E00 Chuoprxr_c Services.-md Senxes that are not available from ASH Office VMt limit:30 visits Ps year Parucipat:n;Prmi ers or other Lcecsed provider with which ASH C hiropractic Supports and appliances:If the as oust of the applmce comaacts to provide covered care You can obtain an=tia:e%an-matiom from any A'H Punc=anns Prov-dez without a referral from a Karma in to ASH Raw fee schedale exceeds SSO.}you w-.L pa}-the amount Permaneme Plan Ptivsiaan.Each office visit counts toward ans-visit litn.-t. to eccess of$30 Covered chuopracnc appliances are Lnuted to elbaa if aFp:icable supports,back supports.cenica_coL•ars,cervical pLlliows.heel hhs.hot or cold packs.:unaa braces and i7jpports.himbar cushions,otrhotcs. wrist support.rb be:ts.home traction units,arkle beeves,knee braces.rib Jpports.and wrist braces T-rav:and laboratory testz:.V_edkal:-v Necessar l-r3v5 and ixnion•tests are covered at no char_e when prescribed a,--part of covered chuopractic care and an ASH Participating Provider provides the Senxes or refer you to another liveried prov:der with whLkASH comaact for the S-n-ues.If vour - -wr,dme,r is Fazed with an HDHP H)10 ev:dence of cover_ze.rh:s cox share:s subject to the PL:n Deducr_ble described m your EOC. ASH Participating Providers ASH PLtns cenni ct w•uh ASH Punc-patin;Providers and other:licensed prat-dens to provide covered C hsopractic Sen-ces You must receive these Alv:ces from an ASH Patic:patm`?rovider of-mother L•versed provider with whah ASH conaact.except for Emememcy Chiropractic Senues. UTi!ent Ch:romactic Services.and Services that are riot available from comtracred umviders th-t are authorized m advance by ASH Plans The:list of ASH Patncroanni Pror-ders:s available on the ASH Pains w•ebute at a:hliaLcon-ashlaisercamedicare for lli:w Pemanim a SenwrAdva:taze member;.or.uhhutLcoin a.hl p foQ a1 other memt-is.or ion:the ASH Plans:ustotner Sen-ce Departmenr toll free at 1-9uMIS-9133,'TTY"ll). The L•st of ASH Pate ipar-q-Providers is subject to cLuzve at any rime without nonce. How to obtain services To obtain covered Seri xes.cal anASH Partcr.anne Provider to schedule an rina:eyan:iwnom a addinomal Senxes are regtmred venficar_on that the Semces are Med:calh Necessary may b?reg:ued Touz A'H Parncpami;Provider wit request any medica:necessm•deierni irons An A SH PLtns cl=mn in the same or s:rntlar sp---ia:n•as the provideT of Services under review wall decide whether the Services are or were Medicaly Neceswv ASH Plans vnl d:sc:ose to you=om rec•.tesi.the w•niten cnreru a uses to make the decision ro rjEhonze.modift•.de:n-.or deav a request for authottzanom you have 4lestons or concetas.please contact the ASH Plans:ustomer S mice Department 6074921 27;P ar ID:142 YOJR KAISER PERNAA%ENTE CHIROPRACTIC KNUIT Second Opinions You may request a second op=on:c regard to covered Services by contacting anotherASH Parrcipaticg Provider An ASH Partiapatcg Provider may also regiest a second orinaon m regard to covered Services by re:errmg you to another ASH Participating Provider in the same or iunalar special Your costs U-1im you receive covered Chiropractic Services.you tout pay the cost share described below.The cost share does not apply toward the P:an Deductible or Plan Out-of-pocket Macisrm described in yotu Health Plan Eridenre q/Covocrgra("Et?t j.unless your Chmprwirc Sdnx#:dnaendNw. r lananfinen(-,:is amending an HSA-Qualified High Deduable Heahh Plan(HDW HMO p:ac evidence of coverage.If`our wnd*e r is paired with an HCHP H V.O evidence of coverage,the cost share you pay for covered Services is subject to the Plan Deductible and Plan Out-of-Pocket Vanmuci described m your EOC. Emergency and Urgent CNropradic Services We co-ei Emergency Chiropractic Services and Urged Chiropractic Services provided by both ASH Participating Provider and Ivor-Participancg Pro:tiers.We do na corer follow-up or continuing care from a hoc-Pairicipatrcg Provider tm:ess ASH Plans has authorized the services is advance. Also.we do not cover servxes from a Non-Putcipaling Provider that ASH Plans determ:ces are cot Exretgency Chiropractic Services or::rzent Chuopracuc Services Getting Assistance oar have a quesnoc or concert reenix-E the Services you received from an ASH Pamciranng Pror ier or another:icensed provider with which ASH Plans contracts.you may call the ASH Pans Cuxomu Service Cepamnect toll free at 1-500-C-S-9133 iTTY 711).weekdays from 5 am.to 6 p in. Pack rime Grievances You can file a grievance with Kinser Perinanetite regarding any issue.Tasty oxvance must e%plarc your Lisue.such as the reasacs,why you believe a decision was in error of why you are dusansfied with Services you received.You may submit sour gneearice orally or in writing to Kaiser Permanenre as descr-bed m your Health Plan EOC Exclusions •Services provided by a chiropranor that are not within the scope of hcecsure for a ch7opractor hcensed in C alifomia •Adjuoctwe therapy not associated wuh spiral muscle.or?o=manipulatior i •Air condmoners,au purifiers.therapeutic mattresses,chuo tactic appliances.durable medico:egyFmmt iupphes.devxe,app-oxes,and aey other item except those listed as covered in Your Amendman. •Services for asthma at addiction.such as ricoane addiction •Hypnotherapy.behavior training,sleet therapy.and weigh.[programs •Thermography •Ecgelimental or invest eatioml Sen-res •CT scans.NM,PET scans.bone scans.eu:ear medicine.and act other n.e of damostic imaeine or radioloev other than t-rays covered under the -Covered Services-secoon of yoJAniendmenr - - - - • Ambulance and other transportation •Educar-on programs.non-medical seS-care or self-he:p.any serf-help physical exercise training.and any re:ated diagnostic testing •Services for pire-employment physicals or yocatwnal rehab:htation •Drugs and medicines.including not-legend or propnetary drugs and meth Ines •Services you receive omide the state of Ca:ifomia exept for Elrergency Chiropractic Services and Tureen Chuopracnc Services •Hospna:services.anesth,eim manipulation under anesthesia,and re:ated services •L:etm and mittmonal supplen:ents,sach as vitamins.=rerals,herbs.herba:products.m•ectable Tapp:ements.and similar products •Vassage therapy •Vaintenar,ce c se i.en_ce.pm%!d2d to mem:+ers whose treatinent records indicate that they have reached maximum therapeutic beneefi�, 5C7432125;Par ID:142 YOJR KAISER PERIVANENTE CHIROPRACTIC BENEFIT Definitions ASH Participating Presider A chiropractor who is lacetised to provide chiropractic services in Califomia and who has a contract vnthASH Plans to Fro u3e�SediczL;Necessary Chiropractic Services to you ASH Plans:American Specialty*Heahh Plans of Cali:omw Inc..a Ca:ifomia corporaron. Chiropractic Services:Chiropractic senzces include zeal and a mem:n'manipulattoe ard ad-ncm therapies such as ultrasotmd.thetapeatic etierciie. or elecuscal muscle sttmulacio&when provided dorm=the same course of treatment and it conjunction A1th cl iropractac manipulative sen-res,and other services provided or presaioed by a chiropracior(intruding Liooratory test..X-rays,and chiropractic supports and appliances j:or the treatmert o's_•our M1s;culoske:etal and Related Disorder Emergency Chiropractic Services::overed Chirarracnc Sen•icei provded for the trearmem of a Musculosk6eta:and Related Disorder>ahich manifests:re2fby acne symptoms of s7a5c.ect severity(mcchic ing severe pam;such that you could eNpect the absence of immediate Chiropractic Sen ices to resat it serious?eopardy to your health or body ftiicnom or organs. Medicay Necessary-A Service is Medically Necessary if it is medica.Uy approprate aid required to prevers.damose.or treat your condition or c:inical sympmuis in accord with;eneraly accepted prafessimal standards of practice that are cor-uirerr wah a standard of care In the medics:community Mosculoskeletal and Related Disorders:Cocdinons with siEm and sti mutoms re:ated to the men-ous.muscuLu and or skeletal systems. Mwculoske:etal and Related Disorders are conditions typically categorized as structuraL degenerative,or it 8atimiawry disorders:or biomechanical dysfimctim of the joints of the body aid or related components of the muscle or skeleta:systems ;muscle i.teadors.fascia.nerves.#31nents capsa:es. discs.and stinot:al strucrtres},and r fared mamfesttnons or conditions. Non-Participating Provider:A prmlder other that ar ASH Participating Prouder. Services:Hearth care sen•tces or items Urgent Chiropractic Services: :h-ropracuc Services that meet a:l of the foLovtmg cequiremeam They are necessary to prec•ent s,mous deterioration o:vo'.0 hea&resulnag iom at.un:areseen:Ilcess.:cjury.or complication of an etistire condition. 3w-%udmg prep=cy. They cannot be delayed und:you ream to the Sen•ice Area This is a summw and is intended to high:ight oily the most ftequert.'y asked questions about the chiropractic benefir.:ic Wzz cost share ?:ease refer to the.;twndflww for a detailed descripnoa of the chiropractic coverage. ■keftml et*HeM 1% KAlSER NERMANENTE- M115 If Udine 0 a--Y�J. 6C7492126:Par ID: 1d_ Language Assistance 1Fm&:f4W��-T .�T24It, �k�ram-.TTm41 wvrw !CT ir T* Services ir f*r.fi'-17 fkIft WMTiraT 91+WMit k f�m,qT ir Eilalish: Lanauaae assistance 3TT=Wirt WWWWWi&1-NO-46a-4000•f-,r-ftrir24 v;,,,wmT-,r wr4t flw(wf m ar4 im w--: 011 aia is available at 1io cost to you. 3�;I m 3-I;iI 1, 711 Tr Tf;q 3�fl 24 hours a day. 7 days a week. H� mg:Niw. ,%-c pab ncbm lus pub cbu-b ran kol. You can request interpreter 24 teev ib hnub mT,7 hnab ib hm tram rw•z Ko;than: tau cor ker pab mbais lus.muab coy-amub n:awz services. materials translated mhais ua hoi hom lus,los row sea lw-m Loom Tsws hu ran 1-800-4"-4000.24:ee;•ib hnub tw•g. 7 h=b ib into your language. or in hmnam rww(coc•hnub cair kaw•) Cov neew sr: alternative fonnnats. Just callus TTl hu 711. at 1-800-464-4000. 24 hours a ;, day. 7 da-y-s a «-eek (closed I-,IMP, W 0 T t*t. 33%falz 1-90""4000 1.TJAW holidays). TTY users call 711. -art! kh1eer:a§tv11 M iM6titiH*93"MIIrjW24 14W46-f-Am OI,a.Sk a.dr sr LA sP� .(711)Ail 'k UzP Ty�-i3L+" riuiu:t�cumeurti�nelcmm�ni�i�{d�9>tic�uis�nh Armenian:dtq tlmgnn t;u*gfi p oq�m alaLh P*Ig3t5gHnU5h 111di S 1400-A"-4000 0122 24 xnnmuuiWtlti ltgo huipemtt•opg 24&.u::. mpuin Vb*gUAt3 71gt�WMifU(ulaigtj U►h UnIO TTY 7 op_`i•mg ZlmIMl 4�Wh4t1�r1nP rauPgumt`h o, mujnLmmfifitp,dughtgQaQ UMUU8 71111 lmligumtntuw 4=ml@ftmjimhVmahh ahw:m*n4 I±,orean 9 "1 '1 of 41Oi 1'r'� �mP�*ub 6lmlat L u qm u'tq 1-800-56l,l000 htmumuuitnuuwgnQ' opt Ajdl-$T$4 al$ r Sttg Ll 4. :4 dmu mwmin 7 Og(=b ogt phh 4=4 t)-TTY-h9 $21 "j dl=, rt Ql Od 01 S� rtl21.1t!7}$5E 3= tj I ogmi�mqhtipa ultu*t gmhquihumt8 711: 11 w4 A 71FL$I V 19 T V a Ll r+-S V- V Al tH Chinese: M7T, - Ig�k 24,l4�1h9uj �+* .1� L4 71tei011-300-464-400031_r. �**IA �.l n L+l • ° lt�'a C:13 1 W*X*f 3"� (-R C 4Pr).TTY 4*4 rd$711. X", V R 7-C Laotian:rt-,tu��cm9o�var-,a-.f?Zu`��; — ii i fOX 24 J,"J4Rkiq.°fTIW 1400-757--7555 A'::$°�lS .1 OA (VIVE {*d,) - hfd �> (1'T7�7{ t arnn-v,mrm9a 24 7 054940.cn'v Mjj@ 711 - a��-�as9�asur��t�vv�ar�a�,taiarJc9rtz* .its►AYA J»7 a i o P3.4.xJ. 24,3 a]4;Z:.":Fars v b r»`1—`L,�t+�i+t+.�W .�.�L&I� ,�4� h ji,% Ja�� a99ari�,aJ, m tTusuauv9v_ �J9 Jw 14 L,U!J6 v ZJt-�&4A&r mcilmsmmon dgsi#1-800-464-4000,mzman 24 4'M Jjj 7 j�j.Ajl seal..24 y C-Al.AA uJPy 14*0-464-4M J-AZ v U 4(.A=, JA*j.slZ6,14,) �Olm5,7 ft6a t9c) _.-LA rW 711.}..:L TrY jl p g.-UA.*W TTY Ims 711. Navajo: Saad bee aka a ayeed niholq t'ai jiWi, Cietnanese:Dinh tv thong dich duac cu=csp mien naadirn doo b2b3a dii aseE ukeed tsosa'id}isJ<>laji phi cho qui t,24 gio moi ngay,'agar u oog rasa Qay danmo na idleeh;i. Atah halne'e iki'adoolwoligu joki, ti co the pea can dick tYL thong dick,tii heu phien dish t'aadoo We t'3a hoha:aadl i hadily;q'go,ei doodah' ra ngon ngu cua quj•ti hoac ti a lieu bang nhieu hinh mina la al*a3 adaat ehigii bee hidaddyaa'go. Koji daic khac Qua=t1 chi cin got cho chnng toi tai so hodulnih 1-800-464-4000.u dan doo bibea'dii` 1-800-464-4000.24 gLo znAI ngiy,7 ngay trong tttsa a&i'iikeed tsosts-id yukaaji damoo na'sdleehji ;trir cac agay le).Nguin dimg TTY-.m goi 711- (Dahodivinbmuye e'e'aahgo ei da'deelkaal). TTY dwdeevoolioigii koji hod,ilnih 711_ P=Jabi:iM W MM t.fv-n t 24 ua,ZT3 t 7°d''C 73-M,"H'tt re 37r3 Fi l,@umau tr 3*ft tf r et 1477 sdt,-;r4 dh r a wnje 3*a*ft w3ry a Ji W'fMX We 1-800-4644000 3,f'rn t 24 WIr,U?3 t 7 fs7, W--;rt. f,-.7 as 7, t3 a#1 TTY a* `ud�Cr a3.rft 711 `Ir a771 Russian:hfat Oecm-THo o6ecoe M3ex Bac ,--nT2.mx nepezom 24 gaca B cyrmL 71Ae$B He=~.,=o Bu xoaere Bo%mo.>b3oB3•Twu noocoa3m}:—mo:o r epesoz a. MMPOCar8 nepeBOZ x3repaa.WB H3 MOX TAM WM WMPOGM H.T B O.HOx M a.ZbTepHM-SMH6LT-C�OF]CITOB. EpO nonozme Haar no Tvze(poxr,1-800-l644000. &oTgn&3LK21IIeH 24 9uza B c%mz.7=HeH B Heze.7ro (spore npaa--mn-mz-zmfi) I o.-m3osarFrt mu= xors-r 3wxm no HOMepy 711 Spans):COsMMoS con asLsteucia de idiom-as 5=costo alpmo pasa used 24 horas al dia. 7 dias 3 La semaba. e?uede solici:ar los serzcaos de un iwerpre:e.que los mrenales se zaduzcan a su Ldioa a o en fo maros ahemanros Solo 1Lme al 1-800-78&0616. 24 horns al dia,7 dias a 13 semana(ce.-rado los dial fesavos).Los usuanos de=--.deben llariar al 711 Tagalog:May magagamit na tulong sa wtka rang w a13 kan_e baba�mran.:4 as oras baw•at craw.7 a_3w b3wa- "ggo. Masan kW hnmin ng mga serbisyo ng tagasahn sa w-tka.mga b3basahin na uinalm sa iyong wtka o sa mga altemaabong format.Tawagan laming ka=sa 1-800-464-4000.24 na ores baA-at araw.7 a.-aw bawat hnggo(samdo s3 mga puts opnyal) Ang m=a gum3gamrt ng TTY ay maaamg=i3%ag sa 711 Thai: LS73EL"sn�saiurl's�iNsLigEYaaaw 24 4iTua >lnivaaawz#ituJrinisLaJLs�REua�uKnbu2>laiai 7 EJa a 1J R 1E117JL clJ q EttYI lfl El 7 ALR 7131 R 7ERSclJ i1KEl lld c�L:'1lTInc7JlS1LLa:gEuiiJ a�uisnualNuctisuilatanai sL4us��n�iigEulrild iaut>irinisRwciiiisnisLrEUJtvis wtsntii-AuiuLav 1-800-464-4000 aaaw 24 :1i�wviniu (17w1111KFl1sLu umEres-iii -is) iilsaiMs' iJr 711 Disclosure Form Part One County of Fresno Group ID 580 - DHMO HSA Low PI Member Services 1-800-464-4000 Home Region: Northern California 12/11/23 through 12/8/24 Principal benefits for Kaiser Permanente HSA-Qualified High Deductible Health Plan ("HDHP") HMO "Kaiser Permanente HSA-Qualified High Deductible Health Plan ("HDHP") HMO" is a health benefit plan that meets the requirements of Section 223(c)(2)of the Internal Revenue Code. For a complete explanation, please refer to the EOC. Health Plan believes this coverage is a "grandfathered health plan" under the Patient Protection and Affordable Care Act. If you have questions about grandfathered health plans, please call Member Services. Accumulation Period The Accumulation Period for this plan is January 1 through December 31. Out-of-Pocket Maximums and Deductibles For Services that apply to the Plan Out-of-Pocket Maximum, you will not pay any more Cost Share for the rest of the Accumulation Period once you have reached the amounts listed below. For Services that are subject to the Plan Deductible or the Drug Deductible, you must pay Charges for covered Services you receive during the Accumulation Period until you reach the deductible amounts listed below. All payments you make toward your deductibles apply to the Plan Out-of-Pocket Maximum amounts listed below. Self-Only Coverage Family Coverage Family Coverage Amounts Per Accumulation Period (a Family of one Member) Each Member in a Family Entire Family of two or of two or more Members more Members Plan Out-of-Pocket Maximum $3,000 $3,000 $6,000 Plan Deductible $3,000 $3,000 $6,000 Drug Deductible Not applicable Not applicable Not applicable Plan Provider Office Visits You Pay Most Primary Care Visits and most Non-Physician Specialist Visits...... No charge after Plan Deductible Most Physician Specialist Visits............................................................. No charge after Plan Deductible Routine physical maintenance exams, including well-woman exams.... No charge (Plan Deductible doesn't apply) Well-child preventive exams (through age 23 months).......................... No charge (Plan Deductible doesn't apply) Scheduled prenatal care exams............................................................. No charge (Plan Deductible doesn't apply) Routine eye exams with a Plan Optometrist.......................................... No charge (Plan Deductible doesn't apply) Urgent care consultations, evaluations, and treatment.......................... No charge after Plan Deductible Most physical, occupational, and speech therapy.................................. No charge after Plan Deductible Telehealth Visits You Pay Primary Care Visits and Non-Physician Specialist Visits by interactive video....................................................................................................... No charge after Plan Deductible Physician Specialist Visits by interactive video...................................... No charge after Plan Deductible Primary Care Visits and Non-Physician Specialist Visits by telephone.. No charge after Plan Deductible Physician Specialist Visits by telephone ................................................ No charge after Plan Deductible Outpatient Services You Pay Outpatient surgery and certain other outpatient procedures.................. No charge after Plan Deductible Most immunizations (including the vaccine)........................................... No charge (Plan Deductible doesn't apply) Most X-rays and laboratory tests............................................................ No charge after Plan Deductible Preventive X-rays, screenings, and laboratory tests as described in the EOC................................................................................................ No charge (Plan Deductible doesn't apply) Hospitalization Services You Pay Room and board, surgery, anesthesia, X-rays, laboratory tests, and drugs..................................................................................................... No charge after Plan Deductible Emergency Health Coverage You Pay Emergency Department visits ................................................................ No charge after Plan Deductible Note: If you are admitted directly to the hospital as an inpatient for covered Services, you will pay the inpatient Cost Share instead of the Emergency Department Cost Share (see "Hospitalization Services"for inpatient Cost Share) Ambulance Services You Pay Ambulance Services............................................................................... No charge after Plan Deductible (continues) Disclosure Form Part One (continued) Prescription Drug Coverage You Pay Covered outpatient items in accord with our drug formulary guidelines: Most generic items (Tier 1) at a Plan Pharmacy or through our mail- No charge for up to a 100-day supply after Plan order service....................................................................................... Deductible Most brand-name items (Tier 2) at a Plan Pharmacy or through our No charge for up to a 100-day supply after Plan mail-order service............................................................................... Deductible Most specialty items (Tier 4)at a Plan Pharmacy............................... No charge for up to a 30-day supply after Plan Deductible Durable Medical Equipment (DME) You Pay Base DME items as described in the EOC............................................. No charge after Plan Deductible Supplemental DME items up to a $2,500 benefit limit per Accumulation Period as described in the EOC..................................... No charge after Plan Deductible Mental Health Services You Pay Inpatient psychiatric hospitalization........................................................ No charge after Plan Deductible Individual outpatient mental health evaluation and treatment................ No charge after Plan Deductible Group outpatient mental health treatment.............................................. No charge after Plan Deductible Substance Use Disorder Treatment You Pay Inpatient detoxification............................................................................ No charge after Plan Deductible Individual outpatient substance use disorder evaluation and treatment No charge after Plan Deductible Group outpatient substance use disorder treatment.............................. No charge after Plan Deductible Home Health Services You Pay Home health care (up to 100 visits per Accumulation Period) ............... No charge after Plan Deductible Other You Pay Eyeglasses or contact lenses: Eyeglass frame every 24 months........................................................ Amount in excess of$200 Allowance (Allowance not subject to Plan Deductible) Regular eyeglass lenses every 12 months.......................................... No charge (Plan Deductible doesn't apply) Contact lenses every 12 months......................................................... Amount in excess of$200 Allowance (Allowance not subject to Plan Deductible) Skilled nursing facility care (up to 100 days per benefit period)............. No charge after Plan Deductible Prosthetic and orthotic devices as described in the EOC...................... No charge after Plan Deductible Diagnosis and treatment of infertility and artificial insemination............. Not covered Assisted reproductive technology ("ART") Services............................... Not covered Hospice care .......................................................................................... No charge after Plan Deductible This is a summary of the most frequently asked-about benefits. This chart does not explain benefits, Cost Share, out-of- pocket maximums, exclusions, or limitations, nor does it list all benefits and Cost Share amounts. For a complete explanation, please refer to the EOC. Please note that we provide all benefits required by law (for example, diabetes testing supplies). 8963.160.2.S000716455 embedded DELTA DENTAL Keepsmil 'ing Delta Dental PPOTM Save with PPO Coordinate dual coverage Visit a dentist in the PP01 network to If you're covered under two plans, ask maximize your savings.2 These dentists your dental office to include information have agreed to reduced fees, and you about both plans with your claim — won't get charged more than your we'll handle the rest. expected share of the bi11.3 Find a PPO Understand transition of care dentist at deltadentalins.com. Generally, multi-stage procedures are Set up an online account covered under your current plan only Get information about your plan, check if treatment began after your plan's benefits and eligibility information, find a effective date of coverage.4 Log in to network dentist and more. Sign up for an your online account to find this date. online account at deltadentalins.com. Get LASIK and hearing aid discounts Check in without an ID card With access to QualSight and Amplifon You don't need a Delta Dental ID card Hearing Health Cares, you can receive when you visit the dentist. Just provide significant savings on LASIK procedures your name, birth date and enrollee ID and hearing aids. To take advantage or Social Security number. If your family of these discounts, call QualSight at members are covered under your plan, 855-248-2020 and Amplifon at they'll need your information. Prefer to 888-779-1429. have an ID card? Simply log in to your account to view or print your card. Save with a PPO dentist .1a * PPO NON-PPO In Texas,Delta Dental Insurance Company provides a dental provider organization(DPO)plan. 2You can still visit any licensed dentist,but your out-of-pocket costs may be higher if you choose a non-PPO dentist.Network dentists are paid contracted fees. 'You are responsible for any applicable deductibles,coinsurance,amounts over annual or lifetime maximums and charges for non-covered services. Out-of-network dentists may bill the difference between their usual fee and Delta Dental's maximum contract allowance. 4 Applies only to procedures covered under your plan.If you began treatment prior to your effective date of coverage,you or your prior carrier is responsible for any costs.Group-and state-specific exceptions may apply.If you are currently undergoing active orthodontic treatment,you may be eligible to continue treatment under Delta Dental PPO.Review your Evidence of Coverage,Summary Plan Description or Group Dental Service Contract for specific details about your plan. 'Vision corrective services and Amplifon's hearing health care services are not insured benefits.Delta Dental makes the vision corrective services program and hearing health care services program available to you to provide access to the preferred pricing for LASIK surgery and for hearing aids and other hearing health services. West Virginia:Learn about our commitment to providing access to a quality dentist network at Copyright©2023 Delta Dental.All rights reserved. deltadentalins.com/about/legal/index-enrollee.html. HL_PPO#135419F(rev.1/23) Benefit Highlights: Delta Dental ppp TM Plan Benefit Highlights for: County of Fresno Group No: 05879 For eligibility details,refer to the plan's Evidence/Certificate of Coverage(on file with your benefits administrator,plan sponsor or employer). Deductibles $50 per person/$150 per family each calendar year Deductibles waived for Diagnostic& Delta Dental PPO dentists:Yes Preventive(D&P)? Non-Delta Dental PPO dentists: No Maximums $2,500 per person each calendar year D&P counts toward maximum? No Waiting Period(s) Basic Services Major Services Prosthodontics Orthodontics None None None None Delta Dental PPO Non-Delta Dental PPO dentists" dentists" Diagnostic&Preventive Services (D & P) 100% 90% Exams,cleanings and x-rays Basic Services 90% 90% Fillings and sealants Endodontics (root canals) 50/ 50% Covered Under Major Services ° Periodontics (gum treatment) 50% 50% Covered Under Major Services Oral Surgery 50% 50% Covered Under Major Services Major Services 50% 50% Crowns,onlays and cast restorations Prosthodontics 50% 50% Bridges,dentures and implants Orthodontic Benefits 100% 100% Adults and dependent children Orthodontic Maximums 100% 100% Adults and dependent children After co-payment After co-payment Orthodontic Maximums Adults(age 20 and over) $1,880 per Case $1,880 per Case One Orthodontic case per lifetime Child(ren)(through age 19) One Orthodontic case per lifetime $1,660 per Case $1,660 per Case Limitations or waiting periods may apply for some benefits;some services may be excluded from your plan.Reimbursement is based on Delta Dental maximum contract allowances and not necessarily each dentist's submitted fees. "'Reimbursement is based on PPO contracted fees for PPO dentists, Premier contracted fees for Premier dentists and program allowance for non-Delta Dental dentists. Delta Dental of California Customer Service Claims Address 560 Mission St., Suite 1300 888-335-8227 P.O. Box 997330 San Francisco, CA 94105 Sacramento, CA 95899-7330 deltadentalins.com This benefit information is not intended or designed to replace or serve as the plan's Evidence of Coverage or Summary Plan Description. If you have specific questions regarding the benefits,limitations or exclusions for your plan,please consult your company's benefits representative. Revised 8/19/2023 Keeo smiling DeltaCare USA j s Dental benefits made easy! Budget-friendly costs When you enroll In a DeltaCare USA,plan.you'll With your DeltaCare USA plan,there are no choose a primary care dentist from our network surprises.You'll know your copayments,and of carefully screened private-practice dentists. your out-of-pocket costs are clearly defined You must visit your primary care dentist to before treatment begins. receive benefits.; • No deductibles or maximums,for covered • No restrictions on pre-existing conditions services (except work In progress) • Pay only your copayment(If any)at the time of •Access to specialty care and out-of-area treatment emergency care Convenient services A partner in oral health We make It easy for you—there are no claim Your DeltaCare USA plan encourages regular forms to complete.and no plan ID card is dental care with an extensive list of covered required to receive treatment. services to help you stay healthy. • Access plan Information online • Low or no copayments for services IIke • Change your primary care dentist by phone or cleanings and exams online LEGAL.40TICEs:Aoca=•cacral and state legal roticas meted to Vow plan:ddtadartallns ccm/about/Iegal/nmxcreolkw.r,tm DeltaCare LSA Is underwrtun n tease states by mesa artluas AL—A oK2 Dental of Anbrra Inc:AZ—Alpna Dertal of Ammna.rx.,CA—Data Dental of Ca IlGrrn;AR,CO,IA,NA NE,Mt MN NC,ND NE N-t OK,OR,RL SC,50 VA,VT,WA,Wt WV—Dentogra Ins.rance Comoary,,AK CT,DC,DE FL,GA,K5,-A MS,MT,Tly WV—Delta>enta iruurance Company HI.D,I-,104 KY,MD,MO,Ka OK Tx—Aptn Danta Programs. nc.:NV—Alpna Dental W hcwam:Inc.;JT —A"Dental or Jtat,Irc,VN—Alpta Dortal of New Mexco Inc,NY—Delta Dental of h w York,Inc.:aA—Delta Dental of PanrsyfVW I3 Delta Dental Insurance Compary acts as trc DeltaCare USA aOmlrlstratd Ir all these states Thaw comparVes are fins-iO31y respenslbla for the,owr p•odlcts Delta Dertal Is a regstored tr3Wrrw-:of Delta Dental awns AssoclatIon rarefy your soectod DeltaCare LSA prrrwy care dent st bdo•c cacti apaolrtrncnt r Pans with an AcOwntal MILry Redo nave a$1,60C anrum maximum for accdcrna Ir ary Consult your EVldcnca/CartTk:ata of Coaerago. 0 y@o ® deltadentalins.com/enrollees SCCAS-D Administered by Delta Dental Insurance Company I-k_DCU_CA424_V23_W_EA_:)4 C113_=R Frequently asked q �._jestions What you need to know about your DeltaCare , USA plan Getting started 4. How much will my dental treatments cost? 1. How do I enroll In a DeltaCare USA plan? How do I pay? Simply complete the enrollment process as With your DeltaCare USA plan,some services are directed by your benefits administrator. Be sure to covered at no cost,while others have a copayment select a primary care network dentist for yourself (amount you pay)for certain services.To find or your dependents,and indicate this dentist and out haw much a treatment will cost,refer to the name of your group wher you enroll. the"Description of Benefits and Copayments" in this brochure for a ist of covered services 2. How do I get started using my and copayments. It's a good idea to bring DeltaCare USA plan? your Evidence/Certificate of Coverage to your Once we process your enrollment,we'll mail you appointment in case you need to discuss your welcome materals that will include: copayment for a service with your dentist. If you have any questions about the charges for a service, • The name,address and phone number of your please contact Customer Service.If you receive selected primary care dentist_Simply call treatment that requires a copayment,simply pay :ne dental facility to make air appointment. the dental facility at the time of service. Important note:In order to receive benefits urde,your plan,you must visit your primary care network dentist for all services.If you require Choosing a dentist treatment from a specialist,your primary care 5. How do I select my primary care dentist? dentist will coordinate a referral for you.You can When you enroll,you must select a prmary care change your primary care dentist by dentist from the DeltaCare LSA network. To contacting us. search'or a dentist,use the Find a dentist tool at • Your Evidence/Certificate of Coverage(plan deltadentalins_com and select the DeltaCare USA booklet).This useful document provides a retwork. You must visit your selected primary care :norough description of how to use your benefits• dentist to use plan benefits.Important:Dental ncluding covered services,covayments and ary services provided by a dentist other than your .imitations and exclusions of your plan. selected primary care dentist will be denied.Your primary care dentist will refer you to a specialist if • An ID card-This card is for your records only— any specialty care is required_ you do no:need to present it in order to receive treatment 6_ Does everyone In my family have to choose the same primary care dentist? 3_ How long will It take to get an appointment No. Each family member can select his or her own with my primary care dentist? primary care network dentist' Two to four weeks s a reasonable amount of time to wait for a routine,non-urgent appointment 7. Can I change my primary care dentist? If you requ re a specific time slot,you may need Yes.You car request:o change you,primary care to wait longer Most DettaCare USA dentists are dentist at any time.Simply visit our website and n private group practices,which generally offer log on to your online account or contact Customer greater appointment availability and extended Service.Selections made by the 15th of the month office hours. are effective immediately.Selections made on or after the 16th of the month will be effective on the first day of the following month. ' In TX,three weeKs is a reasonable amount or cane to wait for a routine.non-urgent appointment In Tx.there is no limit on the number of miles or on the dollar amount per emergency. ` In AZ,MD,and TX,if you do not select a dentist when you enroll,we will choose one for you. ^MA,you cannot select more than three primary care dentist racilltles per family. 8. My dentist says she Is a Delta Dental dentist. 12. Does my plan cover pre-existing conditions? but she Isn't listed In the DeltaCare USA What about treatments that are In progress? directory.Can I still visit her for services? Treatment for pre-exist.rg condit,ons(except work No. Delta Den:a nas many networks,and in progress),including missing or extracted teeth, participation may vary—not all Delta Dental dentists is covered under your plan.Treatment in progress are DeltaCare USA dentists.You must visit your includes services such as preparations for crowns selected primary care network dentist to receive or root canals,or impressions for dentures. If you benefits under this plan. started treatment before your plan's effective date, you and your prior dental carrier are responsible for 9. What should I do If I need to see a specialist? any costs.Some DeltaCare USA plans may cover in- If you require specialty dental care — sach as ora progress orthodontic treatment. surgery,eedodontics,periodontics or pediatric dentistry—contact your primary care dentist to 13. Does my plan cover teeth whitening? request a referral.Specialty dental services not 'Yes. ;Extema. bleachirg is a berefit under your performed by your selected primary care dentist DeltaCare USA plan. Review your plan booklet for must be authorized by us.You are responsible for any more information and talk to your dentist about applicab°e copayments. your options. 14. Does my plan cover tooth-colored fillings General plan information and crowns? 10. If I'm traveling, Is emergency treatment Yes. ;;orce-.ain and other tooth-colored materials are covered under my plan? included in this plan. You and your eligible dependents have out-of-area 15. What If I have additional questions about coverage for dental emergencies'Your out-of- my plan? area emergency benefit(typically limited to$100 Please contact us for add tonal support.Our per person)is for services to relieve pain until you Customer Service representa'ves can answer can return to your primary care network dentist.' benefits questions as well as help you change your Standard plan limitations,exclusions and copayments primary care dentist or arrange for urgent care may apply. referrals.See:he back page of this brochure for our 11. Can I access my plan online? contact information. Yes.Visit delta dental ins.com to create a free,secure online account.You can access your plan benefits and ID card,select(or change)your primary care dentist and more. j State-specific minlmurn distance reoWements may apply. ' In TX,there Is no limit on the number of miles or on the dollar amount per emergency. In TX,there Is no exception for work In progress for coveted DeltaCare USA We • _ it easy for you ! 0 W 0 Select a Pecelve your Schedule an Pecelve Pay only your DeltaCare USA welcome ••• I dental care share to •• dentist Capyngtlt t:2023 Dana Dantal.All rlgrts rosarvoo FAQ_DCU_USA_STD r135998-10(rw OV23) Plan CA42N DeltaCare USA Descriptionof • Copayments SCHEDULE A Description of Benefits and Copayments he Benefits shown below are performed as deemed appropriate by the attending Contract Dentist subject tothe limitations and exclusions of the Prograrrt Please refer to Schedule 8 fcrfurther clarrfi cat ron of Benefits.You should discuss all treatment options with Your Contract Dentist prior to services being rendered. Text that appears in italics below is specifically intended to clarity the delivery of Benefits under the Delta Care USA Program and is not to be interpreted as Current Dental Terminology(-CDT-), CDT-2023 procedure codes,descriptors or nomenclature that are under copyright by the Amencan Dental Association("ADA").The ADA may periodically change CDT codes or definitions. Such updated codes,descriptors and nomenclature may be used to describe these covered procedures in compliance with federal legislation. ENROLLEE CQJ2L QCSCRIPTION PAYS D0100-DO999 I.DIAGNOSTIC D0120 Periodic oral evaluation established patient .......................................................................... No Cost D0140 Limited oral evaluation • problem focused ............. . . No Cost D0145 Oral evaluation for a patient urder three years of age and counseling with primary caregiver ........ No Cost D0150 Comprehensive oral evaluation - new or established patient ..................................................... No Cost D0160 Detailed and extensive oral evaluation - problem focused, by report .......................................... No Cost ............... D0170 Re-evaluation limited,problem focused (established patient;not post-operative visit) ................ No Cost D0171 Re-evaluation postoperative office visit ............................................................................... No Cost D0180 Comprehensive periodortal evaluation - new or established patient .......................................... No Cost D0190 Screening of a patient ..................................... ....... No Cost D0191 Assessment of a patient .......---•----•---....--••---••---••---••---••---•-•...........................................••..... No Cost D0210 Intraoral - comprehensive series of radiographic images -limited to I series every 24 months ........ No Cost D0220 Intraoral - penapical first radiographic image ......... .... No Cost D0230 Intraoral periapical each additional radiographic image .......................................................... No Cost D0240 Intraoral occlusal radiographic image ..................................... .._............. No Cost D0250 Extraoral - 2D projection radiographic image created using a stationary radiation source,and detector ---•----•----•----•----•----•----•----•----•-- -•............................................................ ....... No Cost D0251 Extraoral posterior dental radiographic image ......................................................................... No Cost D0270 Bitewing - single radiographic image ..................................................................................... No Cost D0272 Bitewings - two radiographic images .................................•................................................... No Cost D0273 Bitewings three radiographic images ..................................................................................... No Cost D0274 Bitewings - four radiographic images -limited to 1 series every 6 rnonths ................................... No Cost D0277 Vertical bitewirgs - 7 to 8 radiographic images ....................................................................... No Cost D0330 Panoramic radiographic image ....................................... ...................... No Cost D0415 Collection of microorganisms for culture and sensitivity ........................................................... No Cost D0419 Assessment of salivary flow by measurement- 1 every 12 months .............................................. No Cost D0425 Caries susceptibility tests .............................................................................. .._ No Cost D0460 Pulp vitality tests ................•--•-•--•-•--•-•--•-•--•-•--•-•--................................................................ No Cost D0470Diagnostic casts .................................................................................................................. No Cost D0472 Accession of tissue, gross examination,preparation and transmission of writter report .available only when performed in conjunction with a covered biopsy ...................................................... No Cost D0473 Accession of tissue gross and microscopic examination,preparation and trarsmissior of written report - available only when perfarmed in conjunction with a covered biopsy ............................. No Cost D0474 Accession of tissue, gross and microscopic examination,including assessment of surgical margins for presence of disease, preparation and transmission of written report -available only when performed in conjunction with a covered biopsy ..................................................................... No Cost D0601 Caries risk assessment and documentation,with a finding of low risk - 1 every 12 months .............. No Cost D0602 Caries risk assessment and documentation,with a finding of moderate risk- 1 every 12 months ..... No Cost D0603 Caries risk assessment and documentation,with a finding of high risk - 1 every 12 months ............. No Cost D0701 Panoramic radiographic image - image capture only ............................................................... No Cost D0702 2-D cephalometric radiographic image - image capture only .................................................... No Cost D0703 2-D oral/facial photographic image obtained intro-orally or extra-orally-image capture only ........ No Cost D0705 Extra-oral posterior dental radiographic image - image capture only ......................................... No Cost S-A-CA-STD10-R20 CA42N- 123 Plan CA42N DeltaCare USA Descriptionof • Copayments D0706 Intraoral - occlusal radiographic image . image capture only .................................................... No Cost D0707 Intraoral - periapical radiographic image - image capture only .................................................. No Cost D0708 Intraoral - bitewirg radiographic image . image capture only .................................................... No Cost D0709 Intraoral- comprehensive series of radiographic images - image capture only ............................. No Cost D0999 Unspecified diagnostic procedure,by report -includes office visit,per visit(in addition to other services) ............................................................_............................................................... No Cost D1O00-D1999 II.PREVENTIVE D1110 Prophylaxis cleaning - adult - 1 DIIIO,D1120 or D4346 per 6 rnonth period---------------------------------- No Cost D1110 Additional prophylaxis cleank?g - adult (within the 6 month period) ........................................... $45.00 D1120 Prophylaxis cleaning - child - I D1I10, D1120 or D4346 per 6 month period.................................. No Cost D1120 Additional prophylaxis cleaning - child(within the 6 month period) ........................................... $35.00 D1206 Topical application of fluoride varnish - 1 D1206 or D1208 per 6 month period............................. No Cost D1208 Topical application of fluoride - excluding varnish - 1 D1206 or D1208 per 6 rnonth period............. No Cost D1310 Nutritional counseling for control of dental disease ................................................................. No Cost D1320 Tobacco counseling for the control and prevention of oral disease ............................................ No Cost D1330 Oral hygiene instructions ...................................................................................................... No Cost D1351 Sealant - per tooth - limited to permanent molars through age 15 ............................................. No Cost D1352 Preventive resin restoration in a moderate to high caries risk patient- permanent tooth -limited to permanent molars through age IS .--•-•--•-•--•-•----•--•-•--•-•--•-•-------•-•----•--•-•................................. No Cost D1353 Sealant repair - per tooth - limited to permanent molars through age 15 .................................... No Cost D1354 Application of caries arresting medicament - per tooth - 1 per 6 month period ............................ No Cost D1510 Space mairtainer - fixed unilateral - per quadrant ................................................................. No Cost D1516 Space mairtairer - fixed bilateral, maxillary .........................•................................................ No Cost D1517 Space mairtainer - fixed bilateral, mandibular ....................................................................... No Cost D1520 Space mairtainer . removable unilateral - per quadrant ......................................................... No Cost D1526 Space mairtainer - removable bilateral, maxillary .................................................................. No Cost D1527 Space mairtainer - removable bilateral, mandibular ............................................................... No Cost D1551 Re-cement or re-bord bilateral space mairtairer . maxillary ----------------------------------------------------- No Cost D1552 Re-cernert or re-bord bilateral space mairtairer - mandibular .................................................. No Cost D1553 Re-cement or re-bond unilateral space mairtairer - per quadrant ............................................. No Cost D1556 Removal of fixed unilateral space maintainer - per quadrant ..................................................... No Cost D1557 Removal of fixed bilateral space mairtairer - maxillary ............................................................ No Cost D1558 Removal of fixed bilateral space mairtairer - mandibular ......................................................... No Cost D1575 Distal shoe space mairtairer - fixed,unilateral - per quadrant - child to age 9 ............................. No Cost D2O00-D2999 III.RESTORATIVE lncJudes palistwng, adadhe-eves and bonding agents.,ndirectpulpcappAng,bases,bners andacid etch procedures When there are more than sun crowns rn the same h-eabnent plan,an Enrolee maybe charged an addibonal$125.00 per crown,bey and the 6th urvt. Replacement ofcrownS strays and onlays requires the exisbng restorabon to be 5+years o& Name brand, laboratory processed or in-office processed crown4lponbcs produced through specialized tecMique or matenals are material upgrades The Contract Dentrstmay charge an addibonal fee not to exceed$32500 in addition to Me fated Ccpayment.Refer to LinWabon of Benefits#4 for additional information. D2140 Amalgam - one surface, primary or permanent ....................................................................... No Cost D2150 Amalgam - two surfaces, primary or permanent ...................................................................... No Cost D2160 Ama gam • three surfaces, primary or permanent .................................................................... No Cost D2161 Amalgam - four or more surfaces, primary or permanent ......................................................... No Cost D2330 Resir-based composite one surface, anterior ........................................................................ No Cost D2331 Resir-based composite two surfaces, anterior ...................................................................... No Cost D2332 Resir-based composite three surfaces, anterior .................................................................... No Cost D2335 Resir-based composite - four or more surfaces or involving incisal angle (anterior) ..................... No Cost D2390 Resir-based composite crown, anterior ....................................... ............. No Cost D2391 Resir-based composite ore surface, posterior ...................................................................... $25.00 D2392 Resir-based composite two surfaces, posterior ..................................................................... $30.00 D2393 Resir-based composite three surfaces, posterior ..............................•.................................... $35.00 D2394 Resir-based composite four or more surfaces, posterior ........................................................ $40.00 D2510 Inlay - metallic - ore surface .......................... .... No Cost S-A-CA-STD10-R20 CA42N- V23 Plan CA42N DeltaCare USA Description of Benef Its and Copayments D2520 Inlay - metallic - two surfaces ...................................................•.........................._................ No Cost D2530 Inlay - metallic - three or more surfaces ...........•........................•.._..........._...._.._..................... No Cost D2542 Onlay metallic - two surfaces ............................•.•_......•_................................_.................... No Cost D2543 Onlay metallic three surfaces ............................................................................................ No Cost D2544 Onlay metallic four or more surfaces ................................................................................. No Cost D2610 Inlay - porcelain/ceramic ore surface' .................... . $50.00 D2620 Inlay - porcelain/ceramic two surfaces' ........................ ... $60.00 ..................................................... D2630 Inlay - porcelain/ceramic - three or more surfaces' ........ ..._...... S6S.00 D2642 Onlay porcelair/ceramic - two surfaces' ................ ......... SSS.00 ..................................................... D2643 Onlay porcelain/ceramic - tt-ree surfaces' ..................... ......... $6S.00 D2644 Onlay porcelair/ceramic - four or more surfaces' ............ .. $70.00 D2650 Inlay - resir-based composite - one surface ............................................................................ $15.00 D2651 Inlay - resin-based composite - two surfaces .......................................................................... $20.00 D2652 Inlay - resin-based composite -three or more surfaces ............................................................ $30.00 D2662 Onlay resin-based composite -two surfaces ............................ ...... $25.00 D2663 Onlay resin-based composite - three surfaces ....................................................................... $35.00 D2664 Onlay - resin-based composite - four or more surfaces ............................................................ $50.00 D2710 Crown resin-based composite (indirect) ............................................................................... No Cost D2712 Crown 3/4 resin-based composite (indirect) ......................................................................... No Cost D2720 Crown - resin with high noble metal ............................................................................_......... 530.00 D2721 Crown resin with predominantly base metal ............. ...... $15.00 D2722 Crown resin with noble metal ...................................................... .......... $20.00 D2740 Crown porcelain/ceramic' ..................................•--•-•---...-•-•-•--•----•----•--................_••--....•...... $85.00 D2750 Crown porcelain fused to high noble metal' ............. ....... $70.00 D2751 Crown porcelain fused to predominantly base metal ............................................................. $55.00 D2752 Crown - porcelain fused to noble metal ........................ ... $60.00 ...................................................... D2753 Crown - porcelain fused to titanium and titanium alloys' .......................................................... $70.00 D2780 Crown 3/4 cast high noble metal -----._................... ...... $70.00 D2781 Crown - 3/4 cast predominantly base metal ......................... ..... $55.00 ............................................. D2782 Crown 3/4 cast noble metal .............••---•----•----•----•----•----•----•----•----•----•--••••-••................•••_.. 560.00 D2783 Crown 3/4 porrelair/ceramic' ................................................... ..._.... $70.00 D2790 Crown - full cast high noble metal ............................... ._.. $70.00 D2791 Crown full cast predominantly base metal ..........................•................................................. $55.00 D2792 Crown • full cast noble metal ------.......................................................................................... 560.00 D2794 Crown - titanium and titanium alloys .........................................•..............................._........... $70.00 D2910 Re-cement or re-bond inlay, onlay, veneer or partial coverage restoration ................................... No Cost D2915 Re-cement or re-bond indirectly fabricated or prefabricated post and Gore ................................ No Cost D2920 Re-cement or re-bond crown ..................................................... ........ No Cost D2921 Reattachment of tooth fragment, ircisal edge or cusp (anterior) ............................................... No Cost D2928 Prefabricated porcelain/ceramic crown permanent tooth ........................................................ No Cost D2929 Prefabricated porcelain/ceramic crown primary tooth -anterior .............................................. No Cost D2930 Prefabricated stainless steel crown primary tooth ................................................................. No Cost D2931 Prefabricated stainless steel crown permanent tooth ............................................................. No Cost D2932 Prefabricated resin crown anterior pivnary tooth .................................................................. No Cost D2933 Prefabricated stainless steel crown with resin window -anterior prinary tooth ............................ No Cost D2940 Protective restoration ..............•-•----•-------................................................._..._.._.._._.._._._......... No Cost D2941 Interim therapeutic restoration - primary dentition .................................................................. No Cost D2949 Restorative foundation for an indirect restoration ..............•....•................................................ No Cost D2950 Core buildup, including any Airs when required ......•................................ ................... No Cost D2951 Pin retention - per tooth, in addition to restoration .................................................................. No Cost D2952 Post and core in addition to crown,indirectly fabricated -includes canal preparation ................... No Cost D2953 Each additional indirectly fabricated post - same tooth -includes canal preparation .................... No Cost D2954 Prefabricated post and core in addition to crown -base meta/post,-inctudescanal preparation ..... No Cost D2955Post removal -------•----••--------•----•--•-•----•. ....................................... --....-............ --•--- ------- No Cost D2957 Each additional prefabricated post - same tooth-base metal post,includes canal preparation ...... No Cost S-A-CA-STD10-R20 CA42N - V23 Plan CA42N DeltaCare USA Description of Benefits and Copayments D2960 Labial veneer (resin laminate)-direct - /bnited to replacement of significant tooth structure loss due to caries or fracture ............................................................................ _...._...._. $245.00 D2961 Labial veneer(resin laminate)-indirect - limited to replacement of significant tooth shuctute loss due to caries or fracture ....................................................................................................... $295.00 D2962 Labial vereer(porcelain laminate)- indirect -limited to replacement o f signfficant tooth structure loss due to caries or fracture ..................... .......................................................................... $345.00 D2971 Additional procedures to customize a crown to fit under an existing partial denture framework. ._.__ $14.00 D2980 Crown repair necessitated by restorative material failure .......................................................... No Cost D2981 Inlay repair necessitated by restorative material failure ............................................................. No Cost D2982 Onlay repair necessitated by restorative material failure ........................................................... No Cost D2983 Veneer repair necessitated by restorative material failure ......................................................... No Cost D2990 Resin infiltration of incipient smooth surface lesions -limited topermanentmolars throughage 15. No Cost D3O00-D3999 IV.ENDODONTICS D3110 Pulp cap direct (excluding final restoration) ......................................................................... No Cost D3120 Pulp cap indirect (excluding final restoration) ....................................................................... No Cost D3220 Therapeutic pulpotomy(excluding final restoration) -removal of pulp coronal to the dertirocemertal junction and application of medicament ........................................................ No Cost D3221 Pulpal debridemert, primary and permanent teeth .................. .._ No Cost D3222 Partial pulpotomy for apexogeresis - permanent tooth with incomplete root development ........... No Cost D3230 Pulpal therapy(resorbable filling) -anterior,primary tooth (excluding final restoration) ................ No Cost D3240 Pulpal therapy(resorbable filling) - posterior,primary tooth (excluding final restoration) .............. No Cost D3310 Root canal - endodortic therapy. anterior tooth (excluding final restoration) ............................... $20.00 D3320 Root canal - endodortic therapy,premolar tooth (excluding final restoration) ............................. $40.00 D3330 Root canal - endodortic therapy, molar tooth (excluding final restoration) .................................. $60.00 D3331 Treatment of root canal obstruction; ror-surgical access ......................................................... $40.00 D3332 Incomplete erdodortic therapy; inoperable, urrestorable or fractured tooth ............................... $40.00 D3333 Internal root repair of perforation defects .....................----..---......---....--.----.._.....__......._.....__... $40.00 D3346 Retreatment of previous root canal therapy - anterior .............................................................. $35.00 D3347 Retreatment of previous root canal therapy - premolar ............................................................ $50.00 D3348 Retreatment of previous root canal therapy - molar ................................................................. $95.00 D3351 Apexification/recalcification - initial visit(apical closure/calcific repair of perforations,root resorption, etc) ................................................................................................................... $55.00 D3352 Apexification/recalciflcation - interim medication replacement(apical closure/calcific repair of perforations,root resorption,pulp space disinfection, etc) ....................................................... $45.00 D3353 Apexificatior/recalciflcation - final visit (includes completed root canal therapy -apical closure/ calcific repair of perforations, root resorption,etc) ................................................................. $45.00 D3410 Apicoectomy - anterior ................................................. ..... No Cost D3421 Apicoectomy - premolar (first root) ....................................................................................... No Cost D3425 Apicoectomy - molar(first root) ........................................................................................... No Cost D3426 Apicoectomy (each additional root) ................................................................................_..... No Cost D3430 Retrograde filling - per root ..................................................... ................ No Cost D3450 Root amputation - per root .................................................................................................. No Cost D3471 Surgical repair of root resorption - anterior ............................................................................ No Cost D3472 Surgical repair of root resorption - premolar --------------------------------------------------------------------------- No Cost D3473 Surgical repair of root resorption - molar ............................................................................... No Cost D3501 Surgical exposure of root surface without apicoectomy or repair of root resorption - anterior ........ No Cost D3502 Surgical exposure of root surface without apicoectomy or repair of root resorption - premolar ...... No Cost D3503 Surgical exposure of root surface without apicoectomy or repair of root resorption - molar ---------- No Cost D3920 F%emisection (including any root removal), not including root canal therapy ................................ No Cost D3921 Decororation or submergence of an erupted tooth ................................................................. No Cost D4000-154999 V.PERIODONTICS -1ncAidles pre-operabve and post-cperative evaluations and treatment undera local anesthetic. D4210 Girgivectomy or gingivoplasty - four or more contiguous teeth or tooth bounded spaces per quadrant ............................................................................................................................. No Cost D4211 Girgivectomy or gingivoplasty - one to three contiguous teeth or tooth bounded spaces per quadrant ................................•............................................................................................ No Cost S-A-CA-STD10-R20 CA42N - V23 Plan CA42N DeftaCare USA Descriptionof • Copayments D4212 Girgivectomy or girgivoplasty to allow access for restorative procedure, per tooth ..................... No Cost D4240 Gingival flap procedure,including root planing- four or more contiguous teeth or tooth bounded spacesper quadrant ...............................................................•............................................ No Cost D4241 Gingival flap procedure,including root planing- one to three contiguousteeth or tooth bounded spaces per quadrant ............................................................................................................ No Cost D4245 Apically positioned flap ........................................................................................................ $45.00 D4249 Clinical crown lengthening - hard tissue ............. ... $45.00 D4260 Osseous surgery (including elevation of a full thickness flap and closure) -four or more contiguous teeth or tooth bounded spaces per quadrant ............................. ......... $75.00 D4261 Osseous surgery (including elevation of a full thickness flap and closure) -one to three contiguous teeth or tooth bounded spaces per quadrant ......................................................................... $60.00 D4263 Bore replacement graft - retained ratural tooth - first site in quadrant ...................................... $125.00 D4264 Bore replacement graft - retained natural tooth - each additional site in quadrant ....................... $45.00 D4266 Guided tissue regeneration, natural teeth - resorbable barrier,per site ....................................... $1O0.00 D4267 Guided tissue regeneration, natural teeth - non-resorbable barrier, per site ................................. $140.00 D4270 Pedicle soft tissue graft procedure ........................................................................................ $125.00 D4273 Autogerous corrective tissue graft procedure (including donor and recipient surgical sites)first tooth, implant, or edentulous tooth position in graft ................................................................ $75.00 D4274 Mesial/distal wedge procedure,single tooth (when not performed in conjunction with surgical procedures in the same anatomical area) ............................................................................... No Cost D4275 Nor autogerous corrective tissue graft(including recipient site and donor material)first tooth, implant, or edentulous tooth position in graft ......................................................................... $115.00 D4277 Free soft tissue graft procedure (including recipient and doror surgical sites)first tooth,implant. or edertulous tooth position in graft ..................................................................................... $125.00 D4278 Free soft tissue graft procedure (includirg recipient and doror surgical sites)each additional contiguous tooth, implant,or eclerhilous tooth position in same graft site .................................. $125.00 D4283 Autogenous connective tissue graft procedure (including donor and recipient surgical sites) - each additional contiguous tooth,implant or edentulous tooth position in same graft site .................... $45.00 D4285 Nor-autogerous connective tissue graft procedure (including recipient surgical site and donor material) - each additional contiguous tooth,implant or edentulous tooth position in same graft site ..................................................................................................................................... $69.00 D4286 Removal of non-ressorbable barrier ........................................................................................ $0.00 D4341 PeriodortaI scaling and root plaring - four or more teeth per quadrant-united to 4 quadrants during any 12 consecutive manths ......................................................................................... No Cost D4342 Periodontal scaling and root planing -one to three teeth per quadrant-hvnited to 4 quadrants during any 12 consecutive months ......................................................................................... No Cost D4346 Scaling in presence of generalized moderate or severe gingival inflammation - full mouth,after oral evaluation - I D1110, 011220 or D4346 per 6 month period .......................................................... No Cost D4355 Full mouth debridement to enable a comprehensive periodortal evaluation and diagnosis or a subsequent visit - limited to 1 treatment in any 12 consecutive months ....................................... No Cost D4381 Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue,per tooth - fareach of the first two teeth treated widen a quadrant following root planing or periodontal maintenance .................................................................................................. $60.00 D4 381 Localized delivery of antimicrobial agents via a controlled release vehicle ivito diseased crevicular tissue,per tooth - for an ad&tianal tooth treated in the same quadrant following root pining or periodontal maintenance ...................................................................................................... No Cost D4910 Periodontal maintenance - limited to 1 treatment each 6 month period ...................................... No Cost D4910 Additional periodontal maintenance (within the 6 month period) ............................................... $55.00 D4921 Gingival irrigation with a medicinal agent - per quadrant ......................................................... No Cost D5O00-1015M VI. PROSTHODONTICS(removable) -for a#hsted dentures and partiai dentures, t_apayment.ncluudes after deb very adjus"ents and bssue condiborvng, if needed,for the firstson menthe after placement.torall bsted immediate dentures and imnedate removable partka! dentures. Copayment mclu des other debvery adjusbnents and bssue cond)bonrg,dneeded for the first Mree months 5-A-CA-STD10-R20 CA42N- 123 Plan CA42N Delta Care USA Descriptionof • Copayments after placement. You mist contanue to be elg)blr~ and the service must be provided at the Contract Denbst's fachty where the denture was ongana0y del"red. Rebases, relines and tissue condihommiggare dvn,ted to 1 per denture dirmg any 12 consecubve months Replacement of denture ora partial denture requves the existing denture tote 5+years oJd. D5110 Complete denture maxillary ............................ ...... $75.00 D5120 Complete derture mandibular ............................................................................................. $75.00 D5130 Immediate derture - maxillary .............................................................................................. $85.00 D5140 Immediate derture - mandibular ........................................................................................... $85.00 D5211 Maxillary partial derture- resin base(including retentive/clasping materials,rests,and teeth) ....... $80.00 D5212 Mardibular partial derture- resin base(induding retentive/clasping materials, rests, and teeth) .... $80.00 D5213 Maxillary partial derture- cast metal framework with resin denture bases (including retentive/ clasping materials, rests and teeth) .................................. ._.. $95.00 D5214 Mardibular partial denture- cast metal framework with resin denture bases (including retentive/ clasping materials, rests and teeth) ........................................................................................ $95.00 D5221 Immediate maxillary partial derture - resin base (includirq retertive/claspirq materials,rests,and teeth) ................................................................................................................................. $80.00 D5222 Immediate mandibular partial denture - resin base(includirq retentive/clasping materials,rests, andteeth) ........................................................................................................................... $80.00 D5223 Immediate maxillary partial derture - cast metal framework with resin derture bases(including retentive/claspirq materials, rests and teeth) ______________________________________________...__._.._._............... $95.00 D5224 Immediate mandibular partial denture - cast metal framework with resin denture bases(including retentive/clasping materials, rests and teeth) ............... .... $95.00 D5225 Maxillary partial derture- flexible base (including retentive/clasping materials,rests,and teeth)- prosthetic appliarces will be replaced orly after five years have elapsed from the time of delivery . $195.00 D5226 Mardibular partial denture-flexible base(ircludirg retentive/claspirg materials,rests,and teeth) . $195.00 D5227 Immediate maxillary partial derture - flexible base (including any clasps,rests and teeth) ------------- $80.00 D5228 Immediate mandibular partial denture - flexible base (including any clasps,rests and teeth) ......... $80.00 D5282 Removable unilateral partial denture - ore piece cast metal(including retertive/clasping materials, rests, and teeth), maxillary .....................................•-•--••••...................................................... $80.00 D5283 Removable urilateral partial derture - one piece cast metal(including rententive,/clasping materias, rests, and teeth), mardibular ................................................................................... $80.00 D5284 Removable unilateral partial derture - ore piece flexible base(including retentive/clasping materials, rests, and teeth) - per quadrant .......................... ......................... $80.00 D5286 Removable unilateral partial denture -one piece resin(including retentive/clasping materials,rests. and teeth) - per quadrant ---------------•----.----•----•----•----•-------•-•----•----•----• ---_----- $80.00 D5410 Adjust complete derture - maxillary ........................... ..... No Cost D5411 Adjust complete derture mandibular ..................•._•.._.._._.._._.._.__._.__._.._._................__...__._.._._ No Cost D5421 Adjust partial denture maxillary .......................................................... No Cost D5422 Adjust partial denture mandibular .......................................................... ............ No Cost D5511 Repair broken complete derture base, mandibular .................................................................. No Cost D5512 Repair broker complete denture base, maxillary ..................................................................... No Cost D5520 Replace missing or broker teeth - complete denture (each tooth) ............................................. No Cost D5611 Repair resin partial derture base, mardibular ............. .... No Cost D5612 Repair resin partial derture base, maxillary ........... ...... No Cost ............................................................ D5621 Repair cast partial framework. mardibular ______________________________________________________________________________ No Cost D5622 Repair cast partial framework, maxillary .................................... ...... No Cost D5630 Repair or replace broker retentive/clasping materials - per tooth .............................................. No Cost D5640 Replace broker teeth - per tooth .......................................................................................... No Cost D5650 Add tooth to existing partial denture ..................................................................................... No Cost D5660 Add clasp to existing partial denture - per tooth ........................ ._..__.... No Cost D5670 Replace all teeth and acrylic or cast metal framework (maxillary) ............................................. $65.00 D5671 Replace all teeth and acrylic or cast metal framework (mandibular) .......................................... $65.00 D5710 Rebase complete maxillary denture .....•................................................................................. $30.00 D5711 Rebase complete mardibular derture .................................................................................... $30.00 D5720 Rebase maxillary partial denture ........................................................... ............. $30.00 D5721 Rebase mardibular partial derture ........................................................................ ............ $30.00 D5725 Rebase hybrid prosthesis ....................................... _._ $30.00 D5730 Reline complete maxillary denture (chairside) ......................................................................... No Cost S-A-CA-STD10-R20 CA42N - V23 Plan CA42N DeltaCare USA Descriptionof • Copayments D5731 Reline complete mandibular denture (chairside) ...................................................................... No Cost D5740 Reline maxillary partial denture (chairside) ............................................................................. No Cost D5741 Reline mandibular partial denture (chairside) .......................................................................... No Cost D57SO Reline complete maxillary denture (laboratory) ....................................................................... $25.00 D5751 Reline complete mardibular denture (laboratory) ................ ..... $25.00 ............................................... D5760 Reline maxillary partial denture (laboratory) ........................................................................... $25.00 D5761 Reline mandibular partial denture (laboratory) ........................ ... 525.00 D5765 Soft liner for complete or partial removable denture - indirect .............................................. $25.00 D5820 Interim partial denture (including retentive/clasping materials,rests,and teeth), maxillary -limited to I in any 12 consecutive months ......................................................................................... No Cost D5821 Interim partial denture (including retentive/clasping materials,rests,and teeth), mandibular- limited to I in any 12 consecutive months ............................................................................... No Cost D5850 Tissue conditioning. maxillary ..----•--•-•.................................................................................... No Cost D5851 Tissue conditioning. mandibular ............................................................................................ No Cost D5900-D5999 VII. MAXILLOFACIAL PROSTHETICS - Not Covered 136000-136199 VIII. IMPLANT SERVICES - Not Covered D6200-D6999 IX.PROSTHODONTICS, fixed(each retainer and each pontic cor►stltutes a unit In a fixed partial denture [bridge]) -When a crown anc( orponbc exceeds srx tnots)n the same treatmentpiarl an tnrollee maybe charged an additional $725.00 per u)t,beyond the 6th tnit. -Replacement ofa crown,pontic,uilay, orday or stress breaker regwres the extsttng bridge to be 5+years old. 'Name brand, laboratory processed ortn-office processed crown$/ponbcs produced through specAahzed technque or materials are material tpgrrades The Contract Dentist may charge an addibonal fie not to exceed S-125.00 An addition to the listed Copayment. Refer to Lm to bon of Heneh is 94 for addiU mao�nformatron. D6205 Pontic • indirect resin based composite ................................................................................. $30.00 D6210 Pontic -cast high noble metal .............................................................................................. $70.00 D6211 Pontic - cast predominantly base metal ................................................................................. $55.00 D6212 Pontic cast noble metal ........................•----•----••---••---•----................................--------•----•-_.... $60.00 D6214 Pontic titanium and titanium alloys ......................_._...._...._...._._...._...._..................._...._......... $70.00 D6240 Pontic porcelair fused to high noble metal' ..........................._.._...._.............._...................... $70.00 D6241 Pontic porcelain fused to predominantly base metal .............................................................. $55.00 D6242 Pontic porcelain fused to noble metal ................................. . $60.00 D6243 Pontic porcelain fused to titanium and titanium alloys ........................................................... $60.00 D6245 Pontic porcelair/ceramic' .......................................... .... $70.00 D6250 Pontic resin with high noble metal ...................................................................................... $30.00 D6251 Pontic resin with predominantly base metal ......................................................................... $15.00 D6252 Pontic resin with noble metal .......................•..............................._._.._._.._._.._._.._._.._._.._._.._.. $20.00 D6600 Retainer inlay porcelair/ceramic, two surfaces ............. . $60.00 ........................................................ D6601 Retainer inlay porcelain/ceramic, three or more surfaces ........................................................ $65.00 D6602 Retainer inlay cast high noble metal, two surfaces ................................................................ $70.00 D6603 Retainer inlay - cast high noble metal, three or more surfaces ................................................... $70.00 D6604 Retainer inlay - cast predominantly base metal, two surfaces .................................................... No Cost D6605 Retainer inlay - cast predominantly base metal, three or more surfaces ...................................... No Cost D6606 Retainer inlay cast noble metal, two surfaces ............... ._. $60.00 D6607 Retainer inlay cast noble metal,three or more surfaces ......................................................... $60.00 D6608 Retainer onlay - porcelain/ceramic, two surfaces ................... ................ $55.00 D6609 Retainer orlay - porcelair/ceramic,three or more surfaces ....................................................... $65.00 D6610 Retainer orlay - cast high noble metal, two surfaces ............................................................... $70.00 D6611 Retainer onlay -cast high noble metal, three or more surfaces ................................................. $70.00 D6612 Retainer onlay -cast predominantly base metal, two surfaces ................................................... No Cost D6613 Retainer onlay -cast predominantly base metal, three or more surfaces ..................................... No Cost D6614 Retainer onlay - cast noble metal, two surfaces ...................................................................... $60.00 D6615 Retainer orlay - cast noble metal, three or more surfaces ........................................................ $60.00 .......................... . D6710 Retainer crown - indirect resin based composite ..................................................................... $30.00 D6720 Retainer crown - resin with high noble metal .......................................................................... $30.00 S-A-CA-STD10-R20 CA42N- V23 Plan CA42N DeltaCare USA Description of Benefits and Copayments D6721 Retainer crown - resin with predominantly base metal ............................................................. $15.00 D6722 Retainer crown - resin with noble metal ................................................................................. $20.00 D6740 Retainer crown - porcelain/ceramic' .......................... ...... $70.00 D6750 Retainer crown - porcelain fused to high noble metal' ------------------------------------------------------------- $70.00 D6751 Retainer crown - porcelain fused to predominantly base metal ................................................. $55.00 D6752 Retainer crown - porcelain fused to noble metal ...................................•.•.._.__._...........__...__._.__ $60.00 D6753 Retainer crown - porcelain fused to titanium and titanium alloys' .............................................. $70.00 D6780 Retainer crown - 3/4 cast high noble metal ............................................................................ $70.00 D6781 Retainer crown - 3/4 cast predominantly base metal ............................................................... $55.00 D6782 Retainer crown - 3/4 cast noble metal ................................... ....... $60.00 D6783 Retainer crown - 3/4 porcelair/ceramic' ................................................................................ $70.00 D6784 Retainer crown -titanium and titanium alloys ................................. ............. $70.00 D6790 Retainer crown - full cast high noble metal .............................. ...... $70.00 D6791 Retainer crown -full cast predominantly base metal ......................................... ._............ $50.00 D6792 Retainer crown - full cast noble metal ............................. ......... $60.00 D6794 Retainer crown - titanium and titanium alloys ...................•..................................................... $70.00 D6930 Re-cement or re-bond fixed partial denture ................ .... No Cost D6940Stress breaker ......-•--•-•.................................................................................•..........._._........ No Cost D6980 Fixed partial denture repair necessitated by restorative material failure ...................................... No Cost D7000-D7999 X.ORAL AND MAXILLOFAC IAL SURGERY -IncAides pre-opera bve and post-operative evaluations and treatment undera local anesthetic. D7111 Extraction. cororal remnants - primary tooth .......................................................................... No Cost D7140 Extraction, erupted tooth or exposed root (elevatior and/or forceps removal) ............................ No Cost D7210 Extraction. erupted tooth requiring removal of bone anal/or sectioning of tooth, and inckidhg elevation of mucoperiosteal flap if indicated ......_._. .... $10.00 D7220 Removal of impacted tooth _ soft tissue ................................................................................ $15.00 D7230 Removal of impacted tooth - partially bony ............................................................................ $25.00 D7240 Removal of impacted tooth - completely bony .................... ....... $35.00 D7241 Removal of impacted tooth - completely bony,with unusual surgical complications ..................... $50.00 D7250 Removal of residual tooth roots (cutting procedure) ................................................................ No Cost D7251 Cororectomy - intentional partial tooth removal, impacted teeth only ........................................ $50.00 D7270 Tooth reimplartatior ard/or stabilization of accidentally evulsed or displaced tooth .................... $35.00 D7280 Exposure of an urerupted tooth ....................................................•.•.•.................................. $25.00 D7282 Mobilization of erupted or malpositioned tooth to aid eruption ................................................. $25.00 D7283 Placement of device to facilitate eruption of impacted tooth .................................................... No Cost D7286 Ircisional biopsy of oral tissue- soft - does not include pathology taborafory procedures ............. No Cost D7310 Alveoloplasty in conjunction with extractions- four or more teeth ortooth spaces,per quadrant ... No Cost D7311 Alveoloplasty in conjunction with extractions .one to three teeth or tooth spaces,per quadrant ... No Cost D7320 Alveoloplasty not in conjunction with extractions -four or more teeth or tooth spaces,per quadrant ............................................................................................................................. No Cost D7321 Alveoloplasty not in conjunction with extractions -one to three teeth or tooth spaces,per quadrant .......................................................................................•-•--•-•--•-•--............._ .. No Cost D7450 Removal of benign odontogenic cyst or tumor - lesion diameter up to 125 cm ............................ No Cost D7451 Removal of berign odontogenic cyst or hrmor - lesion diameter greater than 125 cm .................. No Cost D7471 Removal of lateral exostosis (maxilla or mandible) ................................................................... No Cost D7472 Removal of torus palatirus .............................................................................. No Cost D7473 Removal of torus mardibularis .............................................................................................. No Cost D7509 Marsupial ization of odortogeric cyst ..................................................................._................. No Cost D7510 Incision and drainage of abscess - intraoral soft tissue ............................................................. No Cost D7922 Placement of intra-socket biological dressing to aid in hemostasis or clot stabilization,per site ..... No Cost D7961 Buccal/labial frerectomy (frerulectomy) ............. .._.... No Cost D7962 Lingual frerectomy (frenulectomy) ........................................................................................ No Cost D7970 Excision of hyperplastic tissue - per arch ....................................... ........_. No Cost D7971 Excision of pericororal gingiva .............................................................................................. No Cost S-A-CA-STD10-R20 CA42N - V23 Plan CA42N DeftaCare USA Description of Benefits and Copayments D8000-D8999 XI.ORTHODONTICS - The Asted Cgoayment for each phase oforthodonbc treatment(bmted,uitercepbwe orcomprehen-vve)covers up to24 months of active treatment. Beyond 24 month$an adds bonal monthly fee•not to exceed$125.00,may apply. - The Retenti .n Cc payment,ndudes adjustments and/or office visits up to 24 months. Pre and post orthodontk records Include: The benefit for pre-treatment records and diagnostic services includes: ..................................... $200.00 130210 Intraoral - comprehensive series of radiographic images D0322 Tomographic survey D0330 Panoramic radiographic image D0340 2D cephalometric radiographic image - acquisition,measurement and analysis D0350 2D oral/facial photographic images obtained irtraorally or extraorally D0470 Diagnostic casts D0801 3D dental surface scan - direct D0802 3D dental surface scan - indirect D0803 3D facial surface scan - direct D0804 3D facial surface scan - indirect The benefit for post-treatment records includes: .................................. ............ $70.00 130210 Intraoral - comprehensive series of radiographic images D0470 Diagnostic casts D8010 Limited orthodontic treatment of the primary dentition ........................................................... $725.00 D8020 Limited orthodontic treatment of the transitional dentition child or ador*eseent to age 19 ............ $725-00 D8030 Limited orthodontic treatment of the adolescent dentition adolescent to ape 19 ....................... $725.00 D8040 Limited orthodontic treatment of the adult dentition - adults, including covered dependent adult children .............................................................................................................................. $925.00 D8070 Comprehensive orthodontic treatment of the transitional dentition-chdd oradolescent tD age 19. $1.700.00 D8080 Comprehensive orthodontic treatment of the adolescent dentition -adolescent to age 19 ............$1,700.00 D8090 Comprehensive orthodontic treatment of the adult dentition-adults including covered dependent adultchddren ..............................................................................................•-....-•--•-......--....$1,900.00 D8660 Pre-orthodontic treatment examination to monitor growth and development .............................. $25.00 D8670 Periodic orthodontic treatment visit - ,mduded in comprehensive case fee .................................. No Cost D8680 Orthodontic retention. (removal of appliances. construction and placement of removable retainers) ...................................................................................•••••••-•••••.........•••............................... $275.00 D8681 Removable orthodontic retainer adjustment ........................................................................... No Cost D8698 Re-cement or re-bord fixed retainer - maxillary -bmited to 2 per 6 month period ....................... No Cost D8699 Re-cement or re-bord fixed retainer - mandibular - limited to 2per 6 rnonth period.................... No Cost D8701 Repair of fixed retainer,includes reattachment - maxillary- /united to 2 per 6 month period.......... No Cost D8702 Repair of fixed retainer,includes reattachment - mandibular - limited tD 2per 6 month period ....... No Cost D8999 Unspecified orthodontic procedure, by report -includes treatment planning session .................... $100.00 D9000-D9999 XII.ADJUNCTIVE GENERAL SERVICES D9110 Palliative treatment of dental pain - per visit .................................._.._..................._._..__.._....... No Cost D9211 Regional block anesthesia ..................................................................................................... No Cost D9212 Trigemiral division block anesthesia ...................................................................................... No Cost D9215 Local anesthesia it conjunction with operative or surgical procedures ....................................... No Cost D9219 Evaluation far moderate sedation, deep sedation or general anesthesia ..................................... No Cost D9222 Deep sedation/gereral anesthesia - first 15 minutes ................................................................. $80.00 D9223 Deep seclatior/gereral anesthesia - each subsequent 15 minute increment ................................. $80.00 D9239 Intravenous moderate (conscious) sedation/analgesia - first 15 minutes ...................................... $80.00 D9243 Intravenous moderate(conscious)sedation/analgesia - each subsequent 15 minute increment ...... $80.00 D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician ............................................................................................................................. No Cost D9311 Consultation with a medical health care professional ............................................................... No Cost D9430 Office visit for observatior (during regularly scheduled hours)- no other services performed ........ No Cost D9440 Office visit - after regularly scheduled hours _.................................................... ................. $20.00 D9450 Case presentation, subsequent to detailed and extensive treatment planning .............................. No Cost D9912 Pre-visit patient screening .............................................. _....... $0-00 S-A-CA-STD10-R20 CA42N- V23 Plan CA42N DeltaCare USA Description of Benefits and Copayments D9932 Cleaning and inspection of removable complete denture, maxillary -------------------------------------------- No Cost D9933 Cleaning and inspection of removable complete denture, mandibular ........................................ No Cost D9934 Cleaning and inspection of removable partial denture, maxillary ................................................ No Cost D9935 Cleaning and inspection of removable partial denture,mandibular ............................................. No Cost D9943 Occlusal guard adjustment .................................................................................. ..... $10.00 D9944 Occlusal guard hard appliance,full arch •limited to I D9944, D9945 or D9946 in 3years ............ $75.00 D9945 Occlusal guard soft appliance, full arch -IkWted to I D9944,D9945or D9946,m 3 years ............. $75.00 D9946 Occlusal guard hard appliance partial arch -6mitet!to 109944, D9945 of 09946 in 3years ........ $75.00 D9951 Occlusal adjustment, limited ................................................................................................. No Cost D9952 Occlusal adjustment, complete .............................................................................................. No Cost D9975 External bleaching for home application,per arch;includes materials and fabrication of custom trays - #msted to one bleaching bay and gel for two weeks of self-treatment .............................. $125.00 D9986 Missed appointment- without 24 hour notice -per 15 minutes of appointment time- up to an overall maximum of$40.00 .................................................................................................. $10.00 D9987 Canceled appointmert- without 24 hournotice -per 15 minutes of alopointrnent time- up to an overall maximum of$40.00 .................................................................................................. $10.00 D9990 Certified translation or sign-larguage services - per visit .......................................................... No Cost D9991 Dental case margement - addressing appointment compliance barriers ................................... No Cost D9992 Dental case margemert - care coordination ......................................................................... No Cost D9995 Teledertistry - synchronous; real-time encounter ..................................................................... No Cost D9996 Teledertistry- asynchronous;information stored and forwarded to Dentist for subsequent review . No Cost D9997 Dental case management - Patients with special Health Care Needs .......................................... No Cost Procedures with aqe restrictions will be subject toexceptions based on medical necessity. N services for a listed procedure are performed by the Contract Dentist.You pay the specified Copayment.Listed procedures wtwch require a Dentist to provide Specialized Services,and are referred by the Contract Dentist,must be authorized by Us.You pay the Copayment specified for such services. S-A-CA-STD10-R20 CA42N - V23 Limitations and Exclusions of Benefits SCHEDULE B Limitations of Benefits -he frequency of certain H9enefits is limited All frequency limitations are listed in Schedule A,Descrptx>n of Benefits and Copayments 2. If the Enrollee accepts a treatment plan from the Contract Dentist that includes any combination of more than six crowns,bridge pontics and/or bridge retainers,which are supported either by a natural tooth or dental implant,the Enrollee may be charged an additional $100.00 above the listed Copayment for each of these services after the sixth unit has been provided. 3. General anesthesia and/or intravenous sedation/analgesia is limited to treatment by a contracted oral surgeon and in conjunction with an approved referral for the removal of one or more partial or full bony impactions (Procedures D7230,D/240,and D7241). 4. benefits provided by a pediatric Dentist are limited tochildren through age seven following an attempt by the assigned Contract Dentist to treat the child ana upon prior authorization by Us, less applicable Copayments. Exceptions for medical conditions,regardless of age Iimtabon,will be considered on an individual basis. 5. The cost toan Enrollee receiving orthodontic treatment whose coverage is cancelledor terrunatea forany reason will be based on the Contract Orthodontist s submrtted fee forthe treatment plan The Contract Orthodontist will prorate the amount forthe number of months remaining to complete treatment. the Enrollee makes payment airectly to the Contract Orthodontist as arranged. e. Orthodontic treatment in progress is limited to new DeltaCare USA Enrollees who.at the time of theiroriginal effective sate,are in active treatment started under their previous employer sponsorea dental plan,as long as they continue to be eligible under the DeltaCare USA program.Active treatment means tooth movement has begun.Enrollees are responsible for all Copayments and fees subject to the provisions of their prior dental plan. We are financially responsible only for amounts unpaid by the prior dental plan for qualifying orthodontic cases. Exclusions of Benefits . Any procedure that is not specifically listed under Schedule A.Descripbon of Benefits and Copayments. 2. Any procedure that in the professional opinion of the Contract Dentist a has poor prognosis for a successful result and reasonable lorgevity based on the cordition of the tooth or teeth and/or surrourdirg structures,or b. is inconsistent with generally accepted starclards for dentistry. 3. Services solely for cosmetic purposes, with the exception of procedure D9975 (External bleaching for home application,per arch).or for conditions that are a result of hereaitary or developmental defects.such as cleft palate. upper and lower yaw malformations,congenitally missing teeth and teeth that are discolored or lacking enamel,except for the treatment of newborn children with congenital defects or birth abnormalities 4. Porcelain crowns, porcelain fused to metal.cast metal or resin with metal type crowns and fixed partial dentures (bridges)for children under)6 years of age. 5. The replacement of lost or stolen appliances including,but not limited to,full or partial dentures,space maintainers. and crowns and fixed partial dentures(bridges). 6. Procedures,appliances or restoration if the purpose is to change vertical dimension.or to diagnose or treat abnormal conditions of the temporomandibular pint(TMJ). 7. Procedures that may include: a.precious metal for removable appliarces: b. metallic or permarent soft bases for complete dertures; c. porcelair derture teeth; S-B-CA-STD-R21 V2 3 Limitations and Exclusions of Benefits d. precisior abutmerts for removable partials or fixed partial dentures ircluding but not limited to overlays and related specialized appliances; and/or e. persoralization and characterization of complete and partial dentures. 8. Precious metal for removable appliances, metallic or permanent soft bases for complete dentures,porcelain denture teeth. precision abutments for removable partials or fixed partial dentures(overlays. implants,and appliances associated therewith;and personalization and characterization of complete and partial dentures. 9. Consultations for non-covered Benefits. 10. Dental services received from any Dentist other than the assigned Contract Dentist.a preauthorized dental specialist. or a Contract Orthodontist except for Emergency Serv,ces as described in the Contract and/or Lvidence of Coverage. All related fees for admission,use,or stays in a hospital.out-patient surgery center,extended care facility,or other si rrw lar care facil rty. 'Z Prescription drugs. 13. Dental expenses incurred in connection wrath any dental or orthodontic procedure started before Your eIK)ibility with the DeltaCare USA Plan. Bxamples include: teeth prepared for crowns, root canals in progress,full or partial dentures for which an impression has been taken and orthodontics unless qualified forthe orthodontic treatment in progress provi si ort 14. Lost stolen or broken orthodontic appliances_ 15. Changes in orthodontic treatment necessitated by accident of any kind. 1& Myofunc ti onal and parafunctionaI appliances and/or thera pies with the exception of procedures D9944(Occlusal guard, hard appliance,full arch D9945(Occlusal guard- soft appliance,full arch),and D9946(Occlusal guard-hard appliance, partial arch). 17. Composite or ceramic brackets. lingual adapton of orthodontic bands- III Treatment or appliances that are provided by a Dentist whose practice specializes in prosthodontic services. 11 Orthodontic treatment must be provided by a licensed Dentist Self-admrostered orthodontics are not covered. S-B-CA-STD-R21 V2 3 Useful information at your fingertips Boost your wellness 10 Contact us Find oral health resources. Including articles. Need help? Let us know. quizzes, videos and a subscription to Grin!. Online:Visit deltadentalins.com/contact our free dental wellness e-magazine at deltadentallns.com/wellness_ Write to- deltadentalins.com/wellness- Dental Insurance Company Find a network dentist near you 1130 Sanctuary Parkway Use cur convenient Find a dentist tool and Alpharetta, GA 30009 select DeltaCare USA as your n-Etwork_ Call toll-free: 800-422-4234 • Find a dentist near your home or office Customer Service agents are available Monday • Narrow your search by location. specialty, through Friday. 8 am to 9 pm, Eastern time.Or. languages spoken —and more use our automated phone system, available 24/7. Sign up for an online account Sign up for a free. secure online account. • Review your plan benefits • Access your ID card Underwritten by: Administered by: Delta Dental of California Delta Dental Insurance Company 18000 Studebaker Road Suite 530 1130 Sanctuary Parkway Cerritos.CA 90703 Alpharetta,GA 30009 NOTE This Is only a brief summery of your plan. This brocticra Is rot Irtan.'.e=to ropaco your legally rw:Nirad pa-i booklet-Ttia Grcuc Dania Saryco Contract Onto-rlrws the exact tarns and co'idtors of yoLr cove," Please eater to the'Gascrlptian of Bo'farfts arW Copaymarrts' and'L mltatk:ns and Excuslors of Benefits' n tnis ceoctm"for a complete Ist of cowed �"Ocadl.ras,ccpayrnants pxi lire-atlors aro exclusions VOID may also corsJt YOU Evidarco/Cartlresto of Caveragn welch wA be Tailed to on arrollrnart. f ycu wish tc renew an EvldarcQ/Certtfcato of Coverage poor to a�rdlmant yoi.may mauast a copy by calllrg Custorner SwWa at 800-422-42you up Copyngtrt C 2023 ue:a Dental All rigrrts reserved A135998.O2(ray V23) .n ��C�t Vsp BOARD OF DIRECTORS STEVE BRANDAU �� NATHAN MAGSIG VIA BUDDY MENDES San Joaquin Valley LARRYMICARI BRIAN PACHECO Insurance Authority AMYSHUKLIAN PETE VANDER POEL Exhibit B County of Fresno Plan Year 2024 Rates Monthly Rates Bi-Weekly Rates County of Fresno Rates to be remitted to SJVlA Effective January 1,2024 EE ES EC EE ES EC FA FA Anthem PPO$250 $1,187.65 $2,493.10 $2,258.71 $3,444.21 $548.15 $1,150.66 51,042.48 $1,589.64 Anthem PPO$1,500 Retiree $914.24 $1,618.51 $1,428.18 $2,130.68 N/A N/A N/A N/A Anthem PPO$3,000 $653.08 $1,383.36 s $1,240.23 i $1,989.95 $301.42 $638.47 $572.41 $872.28 Anthem EPO 500(includes VSP Vision) $914.86 $1,656.97 $1,452.46 $2,183.13 $422.25 $764.76 $670.38 $1,007.60 Anthem EPO 500(excludes VSP Vision) $906.97 $1,642.79 s $1,438.56 i $2,162.78 $418.61 $758.22 $663.96 $998.21 Anthem EPO 1000(includes VSP Vision) $862.19 $1,561.61 $1,368.95 $2,057.58 $397.94 $720.74 $631.83 $949.65 Anthem EPO 1000(excludes VSP Vision) $854.30 $1,547.43 s $1,355.05 i $2,037.23 $394.30 $714.20 $625.41 $940.26 Anthem EPO 0(includes VSP Vision) $1,055.33 $1,914.09 $1,677.86 $2,522.98 $487.08 $983.43 $774.41 $1,164.45 Anthem EPO 0(excludes VSP Vision) $1,047.44 i $1,899.91 $1,663.96 i $2,502.63 $483.44 $876.89 $767.99 $1,155.06 Kaiser HMO $1,081.86 $1,931.74 $1,704.46 $2,552.27 $499.32 $891.57 $786.67 $1,177.97 Kaiser HDHP $812.78 $1,448.87 s $1,278.75 i $1,913.28 $375.13 $668.71 $590.20 $983.06 Delta Dental PPO $50.29 $80.19 $69.88 $102.58 $23.21 $37.01 $32.25 $47.34 Delta Dental DHMO $27.38 $47.51 $47.83 $68.95 $12.64 $21.93 $22.08 $31.82 VSP Vision $7.89 $14.18 $13.90 520.35 53.64 $6.54 $6.42 $9.39