| † Underwritten by Blue
Shield of California Life & Health Insurance
Company (Blue Shield Life).
ƒ The out-of-pocket/copayment maximums
include the plan deductible.
p The initial flat dollar emergency room
copayment is waived if you are admitted
directly to the hospital as an inpatient.
a Dental services provided through Dental
Benefit Providers (DBP). Benefits limited
to $500 per calendar year. Three month
waiting period following the effective
date of coverage for minor restorative
services.
? Vision exam provided through MESVision
network.
ß The plan is subject to regulatory
approval.
With an HMO plan, members must live or
work within the Blue Shield HMO service
area and have a designated Personal Physician
to enroll and maintain enrollment. The
Blue Shield HMO service area is identified
in the HMO Physician and Hospital Directory.
Each eligible family member may select
a different Personal Physician, as long
as each provider is located adequately
close to the member's home or work address
to ensure access to care (as determined
by Blue Shield).
This information is intended as a brief
comparison of some of the benefits of
the various Blue Shield plans and shows
copay/coinsurance amounts you will pay
for services received from preferred providers
only. You should review the Combined Summary
of Benefits or the Evidence of Coverage/Certificate
of Insurance and Plan Contract/Policy
for a more complete description of the
benefits, terms and conditions and limitations
of the health plans.
Note: The federal Health Insurance Portability
and Accountability Act (HIPAA) makes it
easier for people with pre-existing conditions
who are covered under existing group health
plans to maintain coverage of pre-existing
conditions when they change jobs or are
unemployed for brief periods of time.
If you meet all the specified conditions,
you may be eligible for a guaranteed issue
plan in accordance with HIPAA. For more
information, contact your agent
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