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Classified PopulationEffective July 1, 2013

Access+ HMO plan andShield Spectrum PPO planbenefit summaries

We’re here to helpIf you have any questions, simply contact your dedicated Blue Shield of California Member Services team at (800) 642-6155 for personal assistance. They are available from 7 a.m. to 7 p.m., Monday through Friday. To find network providers and to learn more about your health benefits and additional Blue Shield programs and services, visit blueshieldca.com/sausd.

Santa Ana Unified School District Custom Access+ HMO® Plan - Classified Benefit Summary (For groups of 300 and above)

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. (Uniform Health Plan Benefits and Coverage Matrix)

Blue Shield of California Effective July 1, 2013 Calendar Year Medical Deductible None

Calendar Year Copayment Maximum1 (For many covered services) $1,000 per individual / $2,000 per 2-persons /

$3,000 per family LIFETIME BENEFIT MAXIMUM None

Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits • Physician and specialist office visits

(Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services)

$20 per visit

• Outpatient X-ray, pathology and laboratory No Charge Allergy Testing and Treatment Benefits • Office visits (includes visits for allergy serum injections) $20 per visit Access+ SpecialistSM Benefits1, 2 • Office visit, Examination or Other Consultation (Self-referred office visits and consultations

only) $30 per visit

Preventive Health Benefits • Preventive Health Services (As required by applicable federal and California law.) No Charge OUTPATIENT SERVICES Hospital Benefits (Facility Services) • Outpatient surgery performed at an Ambulatory Surgery Center3 No Charge

No Charge • Outpatient surgery in a hospital No Charge • Outpatient Services for treatment of illness or injury and necessary supplies

(Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) • Inpatient Physician Services No Charge

$250 per admission • Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)

• Inpatient Medically Necessary skilled nursing Services including Subacute Care4, 5 No Charge EMERGENCY HEALTH COVERAGE

$100 per visit • Emergency room Services not resulting in admission (Copayment does not apply if the member is directly admitted to the hospital for inpatient services)

No Charge • Emergency room Physician Services AMBULANCE SERVICES • Emergency or authorized transport No Charge PROSTHETICS/ORTHOTICS • Prosthetic equipment and devices (Separate office visit copay may apply) No Charge • Orthotic equipment and devices (Separate office visit copay may apply) No Charge DURABLE MEDICAL EQUIPMENT

No Charge • Breast Pump • Durable Medical Equipment No Charge MENTAL HEALTH SERVICES (PSYCHIATRIC)6

• Inpatient Hospital Services No Charge • Outpatient Mental Health Services $10 per visit

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Covered Services Member Copayment CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)7,10

A description of your chemical dependency benefits is provided separately

• Chemical dependency and substance abuse services

HOME HEALTH SERVICES $20 per visit • Home health care agency Services (up to 100 visits per Calendar Year) No Charge • Medical supplies and laboratory Services

OTHER Hospice Program Benefits10 • Routine home care No Charge • Inpatient Respite Care No Charge • 24-hour Continuous Home Care No Charge • General Inpatient care No Charge Pregnancy and Maternity Care Benefits • Prenatal and postnatal Physician office visits

(For inpatient hospital services, see "Hospitalization Services.") No Charge

Family Planning Benefits • Counseling and consulting8 No Charge • Infertility Services (member share is based upon allowed charges)

(Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT).

50%

• Tubal ligation No Charge • Elective abortion9 $100 per surgery • Vasectomy9 $75 per surgery Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) • Office location (Copayment applies to all places of services, including professional and facility settings) $20 per visit Speech Therapy Benefits

$20 per visit • Office Visit - Services by licensed speech therapists (Copayment applies to all places of services, including professional and facility settings)

Diabetes Care Benefits No Charge • Devices, equipment, and non-testing supplies (member share is based upon allowed

charges.) $20 per visit • Diabetes self-management training

Hearing Aid Benefits No Charge • Hearing Aid Instrument and ancillary equipment (Plan payment up to $2,000 every 24

months) $20 per visit • Audiological Exams

Urgent Care Benefits (BlueCard® Program) • Urgent Services outside your Personal Physician Service Area $50 per visit Optional Benefits1 Optional dental, vision, infertility, substance abuse, chiropractic or chiropractic and acupuncture

benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately.

1 Copayments marked with this footnote do not accrue to the calendar-year copayment maximum. Copayments and charges for services not accruing to the member's calendar-year copayment maximum continue to be the member's responsibility after the calendar-year copayment maximum is reached. Please refer to the Evidence of Coverage and the Plan Contract for exact terms and conditions of coverage.

2 To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by a MHSA network participating provider.

3 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits.

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

5 Skilled nursing services are limited to 100 preauthorized days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities.

6 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage and Plan Contract.

7 Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield HMO providers.

8 Includes insertion of IUD as well as injectable contraceptives for women.

9 Physician services copayment in the office or outpatient hospital facility only. If procedure is performed in a hospital facility setting, additional hospital services copayment may apply. Optional substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as "Additional Substance Abuse Treatment Benefits."

10

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Santa Ana Unified School District Chiropractic Benefits Additional coverage for your Access+ HMO® Blue Shield Chiropractic Care coverage lets you self-refer to a network of more than 3,310 licensed chiropractors. Benefits are provided through a contract with American Specialty Health Plans of California, Inc. (ASH Plans).

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

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

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

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

Initial and subsequent examinations

Office visits and adjustments (subject to annual limits)

Adjunctive therapies

X-rays (chiropractic only)

Benefit Plan Design

Calendar-year Maximum 30 Visits

Calendar-year Deductible None

Calendar-year Chiropractic Appliances Benefit1,2

$50

Covered Services Member Copayment

Chiropractic Services $10

Out-of-network Coverage None

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

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

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

Friendly Customer Service Helpful ASH Plans Member Services representatives are available at (800) 678-9133 Monday through Friday from 6 a.m. to 5 p.m. to answer questions, assist with problems, or help locate a participating chiropractor.

This document is only a summary for informational purposes. It is not a contract. Please refer to the Evidence of Coverage and the Group Health Service Agreement for the exact terms and conditions of coverage.

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Santa Ana Unified School District Substance Abuse Treatment Benefits For Access+ HMO® Plan- Classified Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix)

How the Plan Works In addition to the benefits listed in the Benefit Summary, your health plan also covers inpatient hospital and professional (physician) services for substance abuse treatment and rehabilitation provided via hospitalization or partial hospitalization/day treatment.1 All services must be medically necessary. Blue Shield of California has contracted with a Mental Health Service Administrator (MHSA), a licensed specialized health care service plan, to administer and deliver these services from MHSA participating providers. The MHSA is only the administrator for participating providers. Blue Shield of California does not provide benefits for services provided by non-participating providers.

Coverage Details Residential care is not covered.

Covered Services Member Copayment2

MHSA Participating Provider

Inpatient Hospitalization No Charge

Professional (Physician) Services - Inpatient and Outpatient Physician Visit

$10 per visit

Partial Hospitalization/Day Treatment Ambulatory Surgery Copay Applies

1. Except for emergencies, benefits are covered only when pre-authorized by the MHSA.

2. Please refer to the Medical Benefit Summary for applicable copayment responsibility.

This document is only a summary for informational purposes. It is not a contract. Please refer to the Plan Contract and Evidence of Coverage for the exact terms and conditions of coverage.

Santa Ana Unified School District Custom Shield Spectrum PPOSM -Classified Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)

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

Blue Shield of California Effective July 1, 2013 Preferred Providers1 Non-Preferred Providers1

$300 per individual / $600 per family

$600 per individual / Calendar Year Medical Deductible (All providers combined)2 $1,200 per family Calendar Year Copayment Maximum2 (Copayments for Preferred Providers accrue to both Preferred and Non-Preferred Provider Calendar-year Copayment Maximum amounts.)

$1,000 per individual $2,000 per individual

LIFETIME BENEFIT MAXIMUM None

Covered Services Member Copayment PROFESSIONAL SERVICES Preferred Providers1 Non-Preferred Providers1 Professional (Physician) Benefits

$20 per visit • Physician and specialist office visits (Not subject to the Calendar-Year

Deductible)

30%

• CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine3(prior authorization is required)

20% 30%

• Other outpatient X-ray, pathology and laboratory (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities)3

20% 30%

Allergy Testing and Treatment Benefits • Office visits (includes visits for allergy serum injections) 10% 30% Preventive Health Benefits • Preventive Health Services (As required by applicable federal and California

law.) No Charge

(Not subject to the Calendar-Year Deductible)

30%

OUTPATIENT SERVICES Hospital Benefits (Facility Services) • Outpatient surgery performed at an Ambulatory Surgery Center4 10% 30%5

• Outpatient surgery in a hospital 10% 30%5

• Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under "Rehabilitation Benefits")

10% 30%5

• CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital (prior authorization is required)3

20% 30%5

• Other outpatient X-ray, pathology and laboratory performed in a hospital3

20% 30%5

• Bariatric Surgery (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only)6

10% 30%5

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) • Inpatient Physician Services 10% 30% • Inpatient Non-emergency Facility Services (Semi-private room and board,

and medically-necessary Services and supplies, including Subacute Care) 10% 30%7

• Bariatric Surgery (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only)6

30%7 10%

Skilled Nursing Facility Benefits8, 9 (Combined maximum of up to 100 prior authorized days per Calendar Year; semi-private accommodations)

10% • Services by a free-standing Skilled Nursing Facility

10%9

• Skilled Nursing Unit of a Hospital 30%7 10%

Covered Services Member Copayment EMERGENCY HEALTH COVERAGE • Emergency room Services not resulting in admission (Copayment does

not apply if the member is directly admitted to the hospital for inpatient services) (If ER services do not result in a direct admission the Calendar-Year Deductible does not apply)

$100 per visit $100 per visit

• Emergency room Services resulting in admission (when the member is admitted directly from the ER)

10% 10%

• Emergency room Physician Services 10% 10% AMBULANCE SERVICES • Emergency or authorized transport 10% 10% PROSTHETICS/ORTHOTICS • Prosthetic equipment and devices (Separate office visit copay may apply) 10% 30%

10% 30% • Orthotic equipment and devices (Separate office visit copay may apply)

DURABLE MEDICAL EQUIPMENT • Breast Pump No Charge

(Not subject to the Calendar-Year Deductible)

30%

• Durable Medical Equipment 20% 30% MENTAL HEALTH SERVICES (PSYCHIATRIC)10 MHSA Participating

Providers1 MHSA Non-Participating

Providers1 30%7 10% • Inpatient Hospital Services

$10 per visit (Not subject to the Calendar-Year

Deductible)

30% • Outpatient Mental Health Services

CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)11 Please see footnote 15 • Chemical dependency and substance abuse services A description of your chemical dependency benefit is

provided separately HOME HEALTH SERVICES12 Preferred Providers1 Non-Preferred Providers1 • Home health care agency Services8 (up to 100 prior authorized visits per

Calendar Year) 20% Not Covered12

• Home infusion/home intravenous injectable therapy and infusion nursing visits provided by a Home Infusion Agency

20% Not Covered12

OTHER Hospice Program Benefits12 • Routine home care No Charge

(Not subject to the Calendar-Year Deductible)

Not Covered12

No Charge • Inpatient Respite Care (Not subject to the Calendar-Year

Deductible)

Not Covered12

• 24-hour Continuous Home Care 10% Not Covered12

• General Inpatient care 10% Not Covered12

Chiropractic Benefits8 • Chiropractic Services - (provided by a chiropractor)

(up to 50 visits per Calendar Year) 20% 30%

Acupuncture Benefits • Acupuncture 20% 20% Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) • Office location 20% 30% Speech Therapy Benefits

20% 20% • Office Visit - Services by licensed speech therapists Pregnancy and Maternity Care Benefits

10% 30%

• Prenatal and postnatal Physician office visits (For inpatient hospital services, see "Hospitalization Services.")

Covered Services Member Copayment Family Planning Benefits • Counseling and consulting13 No Charge

(Not subject to the Calendar-Year Deductible)

Not Covered

• Intrauterine Device (IUD) (includes insertion and removal of IUD)

• Elective abortion14

No Charge (Not subject to the Calendar-Year

Deductible) 10%

30%

Not Covered • Tubal ligation No Charge

(Not subject to the Calendar-Year Deductible)

Not Covered

• Vasectomy14 10% Not Covered Diabetes Care Benefits • Devices, equipment, and non-testing supplies 20% 30% • Diabetes self-management training (If billed by your provider, you will also be

responsible for the office visit copayment) $20 per visit 30%

Hearing Aid Benefits • Hearing Aid Instrument and ancillary equipment (Plan payment up to

$2,000 every 24 months) No Charge

(Not subject to the Calendar-Year Deductible)

30%

• Audiological exams $20 per visit 30% (Not subject to the Calendar-Year

Deductible) Care Outside of Plan Service Area (Benefits provided through the BlueCard® Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) • Within US: BlueCard Program See Applicable Benefit See Applicable Benefit

See Applicable Benefit See Applicable Benefit • Outside of US: BlueCard Worldwide

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

1 Member is responsible for copayment in addition to any charges above allowable amounts. The copayment percentage indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield's allowable amount as full payment for covered services. Non-preferred providers can charge more than these amounts. When members use non-preferred providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield's allowable amount. Charges above the allowable amount do not count toward the calendar-year deductible or copayment maximum.

2 Deductible and copayments marked with this footnote do not accrue to calendar-year copayment maximum. Copayments and charges for services not accruing to the member's calendar-year copayment maximum continue to be the member's responsibility after the calendar-year copayment maximum is reached. Deductible does not apply toward the calendar-year maximum. Please refer to the Evidence of Coverage and the Plan Contract for exact terms and conditions of coverage.

3 Participating non Hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits.

4 Participating ambulatory surgery facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits.

5 The maximum allowed charges for non-emergency surgery and services performed in a non-participating Ambulatory Surgery Center or outpatient unit of a non-preferred hospital is $1,500 per day. Members are responsible for 30% of this $1,500 per day, plus all charges in excess of $1,500.

6 Bariatric surgery is covered when pre-authorized by the Plan. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage for further benefit details.

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

8 For plans with a calendar-year medical deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan medical deductible has been met.

9 Services may require prior authorization by the Plan. When services are prior authorized, members pay the preferred or participating provider amount. 10 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) - using Blue Shield's MHSA participating and non-participating

providers. Only Blue Shield MHSA contracted providers are administered by the Blue Shield MHSA. Behavioral health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage and Plan Contract.

11 Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's preferred providers or non-preferred providers.

12 Out of network home health care, home infusion and hospice services are not covered unless pre-authorized. When these services are pre-authorized, the member pays the Preferred Provider copayment.

13 Includes injectable contraceptives for women. 14 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment

may apply. Services from non-participating providers and non-preferred facilities are not covered under this benefit. Optional substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as "Additional Substance Abuse Treatment Benefits."

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Santa Ana Unified School District Substance Abuse Treatment Benefits For Shield Spectrum PPOSM Plans Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix)

How the Plan Works In addition to the benefits listed in the Benefit Summary, your health plan also covers inpatient hospital and professional (physician) services for substance abuse treatment and rehabilitation provided via hospitalization or partial hospitalization/day treatment.1 All services must be medically necessary. Blue Shield of California has contracted with a Mental Health Service Administrator (MHSA), a licensed specialized health care service plan, to administer and deliver these services from MHSA participating providers. The MHSA is only the administrator for participating providers, and does not administer non-participating providers.

Coverage Details Residential care is not covered. Out of pocket costs are lowest when you receive care from an MHSA participating provider.

Covered Services Member Copayment3

MHSA Participating Provider* MHSA Non-Participating Provider2

Inpatient Hospital Inpatient Hospitalization Copay Applies Inpatient Hospitalization Copay Applies

Professional (Physician) Services - Inpatient and Outpatient Physician Visit

Physician Visit Copay Applies Physician Visit Copay Applies

1. Except for emergencies, benefits are covered only when pre-authorized by the MHSA.

2. Member is responsible for a copayment in addition to any charges above allowable amounts from non-participating providers. MHSA participating providers accept Blue Shield’s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts. When members use non-participating providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield’s allowable amount.

3. Please refer to the Medical Benefit Summary for applicable copayment responsibility.

* Copayments are calculated based on the negotiated rate with participating providers.

This is only a summary of the additional substance abuse treatment benefits not described in the Uniform Benefits and Coverage Matrix. It is not a contract. Please refer to the Plan Contract and Evidence of Coverage for a detailed description of covered benefits and limitations.

Notice on the availability of language assistance services to accompany vital documents issued in English IMPORTANT: Can you read this letter? If not, we can have somebody help you read it.

You may also be able to get this letter written in your language. For free help, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) 346-7198.

IMPORTANTE: ¿Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Blue Shield o al (866) 346-7198.

(Spanish)

重要通知：您能讀懂這封信嗎？ 如果不能，我們可以請人幫您閱讀。

這封信也可以用您所講的語言書寫。 如需幫助，請立即撥打登列在您的Blue

Shield ID卡背面上的會員/客戶服務部的電話，或者撥打電話866-346-7198。 (Chinese)

QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/Khách hàng theo số ở mặt sau thẻ ID Blue Shield của quý vị hoặc theo số 866-346-7198. (Vietnamese)

12 Blue Shield of California

notes