CHOICE Administrators Program Reference Guide CHOICE Administrators® Program Reference Guideis designed to provide you with ... Tulare Tuolumne Ventura ... Adds/Terms Fax 714-558-8000

®

Program Reference

Guide

CHOICE Administrators

offers five programs for groups with 2-199 employ-ees. The CaliforniaChoice

Exchange provides access to full and discounted provider networks through Anthem Blue Cross, Health Net,

Kaiser Permanente, Sharp Health Plan

and Western Health Advantage - all in one program. The HSA California Exchange

reduces premiums and lowers taxes and it’s the only HSA program that offers 3 health plans in one

program - Health Net, Kaiser Permanente and Western Health Advantage. Kaiser Permanente Choice Solution offers Kaiser Permanente

through a variety of plans that fit any budget. Choice

Builder is the nation’s only ancillary Exchange

that offers dental, vision, and chiropractic and life

insurance from Delta Dental, Ameritas Group,

Assurity Life Insurance Companies, EyeMed

Vision Care, Landmark Healthcare, Madison

National Life Insurance C o m p a n y a n d V S P.

The CaliforniaChoice 51+ Exchange lets employers

with 51 to 199 employees control their budget

while offering employees all the benefits they

want a t p r ices t h e y c a n a f f o r d t h r o u g h

Health Net and Kaiser Permanente. C H O I C E

Administrators programs offer contributory and

voluntary ancillary benefits through American Specialty

Health, Ameritas Group, Assurity Life Insurance

C o m p a n y, C a l P e r k s Discounts, CHOICE Administrators Payroll Services-Powered by Ovation Payroll. CONEXIS

– Section 125 POP, Delta Dental, EPIC Hearing Health Care, EyeMed Vision Care, Landmark Healthcare.

Q1:2013

Program Reference Guide

Contents

TO OUR BROKERS:The information in this reference guide is accurate to the best of our knowledge at the time of printing. However, since thispublication is intended strictly as a guide – and plan specifications may change – we recommend that you verify any data with your CHOICE Administrators sales representative before basing any decisions on the information provided.

The CHOICE Administrators® Program Reference Guide is designed to provide you with the most up-to-date information on the programs offered by CHOICE Administrators – the underwriting, eligibility and participation requirements, enrollment documentation, plan co-pays, and much more.

It also includes contact information for all product lines – including the names of renewal specialistsin your area who are ready, willing, and able to assist you with your renewals.

MEDICAL

CaliforniaChoice® ............................................................3 CaliforniaChoice 51+ ....................................................13 HSA California® ..............................................................23 Kaiser Permanente Choice Solution..............................31 Additional Health Plan Comparison Information..........37

ANCILLARY CONSUMER EXCHANGE PROGRAM

Choice Builder®..............................................................41

DENTAL

CaliforniaChoice ............................................................47 CaliforniaChoice 51+ ....................................................49 HSA California ..............................................................51 Kaiser Permanente Choice Solution..............................53

www.choiceadmin.com

If you ever have any questions about coverages, or need a quote, please contact the appropriate program listed below:

Important Telephone Numbers

2

(800) 542-4218

(866) 226-7431

(866) 251-4625

(800) 416-4395

(866) 412-9254

MEDICAL www.choiceadmin.com

Colusa

Calaveras Marin

Monterey

Sacra- mento

Alameda

Alpine Amador

Butte

Contra Costa

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Madera

Mariposa

Mendocino

Merced

Modoc

Mono

Napa

Nevada

Orange

Placer

Plumas

Riverside

San Benito

San Bernardino

San Diego

San Francisco

San Joaquin

San Luis

Obispo

San Mateo

Santa Barbara

Santa Clara

Santa Cruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sut- ter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo

Yuba Lakke La

�PPO Only Counties

HMO & PPO Counties Plan may not be available in all ZIP Codes within county. Check with your CaliforniaChoice representative to confirm if coverage is available for your group location.

3

(See next page for carrier telephoneand address information)

4

CaliforniaChoice®Carrier Contact Information

Member SupportCaliforniaChoice Customer Service Center 800-558-8003Aetna 888-702-3862Anthem Blue Cross 866-524-5659Health Net 800-361-3366Kaiser Permanente

English 800-464-4000Spanish 800-788-0616

Sharp Health Plan 800-359-2002Western Health Advantage 888-563-2250

Bilingual Support 800-558-8003, Press #9 for Spanish

Internet Support www.calchoice.com

Provider Eligibility Verification 800-558-8003

Broker Services & Commissions 714-542-6992 - Ext. 4390

Broker of Record Changes Fax 714-972-7368

Adds/Terms Fax 714-558-8000E-mail: [email protected]

Billing Questions 800-558-8003

Claims Contact carriers directly

To contact by mail, or for payment submission: CaliforniaChoice

721 South Parker, Suite 200Orange, CA 92868

Tax ID Number 33-0115986

www.choiceadmin.com MEDICAL

CaliforniaChoice®

Available

Discount or Buy-up

Discount or Buy-up

Not Available

Chiro only or Chiro & Acupuncture Riders Available

Combined Chiro & Acupuncture Rider Available

Varies by HCSP

Aetna Value NetworkAnthem Blue Cross PPOAnthem Blue Cross HMOAnthem Blue Cross Select HMOHealth Net HMOElect Open Access (from Health Net)

Salud HMO y MásHealth Net Silver HMOKaiser Permanente HMOSharp Health Plan HMOWestern Health Advantage HMO

How often can members change their Primary Care Physician (PCP)?

Can family members each choose a PCP from a differentIPA/Medical Group?

Refer to summary on pages 8-9

Refer to summary on pages 8-9Maximum Choice For EmployeesEach employee's health care needs are different. The CaliforniaChoiceprogram provides employees the maximum choice in meeting thoseneeds with these health plans—all within one program:

HMO

2-50

Networks vary according toHealth Care Service Plan (HCSP)

No

No

Yes

PLEASE NOTE: Not all health plans are available in all areas

Products Offered

Multi Option (Mix And Match)

OptionalBenefits

Provider Information

CaliforniaChoice PPO Guidelines

For Salud HMO y Más,only Salud network

optional benefits areshown here. SIMNSA

network benefits vary—call your CaliforniaChoicerepresentative for details

CaliforniaChoice

CaliforniaChoice®

CaliforniaChoice

LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

24 HOUR COVERAGE

SPECIALIST REFERRALS

Self-referral available?

Express referral available?Varies by Health Care Service Plan (See summary on pages 8-9)

Varies by Health Care Service Plan (See summary on pages 8-9)

Consumer-Directed Healthcare

HSA-Compatible PPO HRA-CompatiblePPO

MRP-CompatiblePPOLumenos HSA 1800 †*

Lumenos HSA 2500 †*

N/A

N/A

CalChoice® HMO 15CalChoice HMO 25

CalChoice HMO 25 ValueCalChoice HMO 30

CalChoice HMO 30 ValueCalChoice HMO 40

CalChoice HMO 40 ValueElect Open Access 25

Elect Open Access 25+ Elect Open Access 40+

Salud HMO y MásSalud Mexico

PPOCalChoice PPO 750 †

CalChoice PPO 750 GenRx †

CalChoice PPO 1000 †

CalChoice PPO 1000 GenRx †



Healthy Support CalChoice PPO 1500Healthy Support CalChoice PPO 1750 GenRx

CaliforniaChoice

Is Workers' Comp required on corporate officers, partners and sole proprietors?

Is on-the-job covered for corporate officers, partners and sole proprietors?

Is there a premium adjustment for24 hour coverage?

SELECTION

NETWORKS

* HSA-Qualified High Deductible Health Plan† PPO plan availability based on group eligibility and may be subject to change

† PPO plan availability based on group eligibility and may be subject to change

5

www.choiceadmin.comMEDICAL

GROUP SIZE

10+ medically enrolled

employees

COBRA enrollees are not counted toward total group size.“Life Only” enrollees are not counted toward total group size.

“Dental Only” enrollees are not counted toward total group size.

Group Size Plans Available

2-9 medically enrolled

employees

All HMO and HMO Value Plans and CalChoice PPO 750 GenRx, CalChoice PPO 1000, CalChoice PPO 1000 GenRx, CalChoice PPO 3000,

CalChoice PPO 4000, Lumenos HSA 1800, Lumenos HSA 2500, Healthy Support CalChoice PPO 1500 & Healthy Support CalChoice PPO 1750 GenRx

All HMO and HMO Value Plans and CalChoice PPO 750, CalChoice PPO 750 GenRx,CalChoice PPO 1000, CalChoice PPO 1000 GenRx, CalChoice PPO 3000,

CalChoice PPO 4000, Lumenos HSA 1800, Lumenos HSA 2500,Healthy Support CalChoice PPO 1500 & Healthy Support CalChoice PPO 1750 GenRx

GROUP SIZE

COVERAGE RESTRICTIONS

Are commission employees allowed? Yes—if on quarterly/annual wage report and showing atleast minimum wages and withholdings

Are 1099 employees allowed? No

Are employees covered if traveling out of USA?Only for emergency benefits

Is coverage available for out-of-state employees? Yes—CalChoice PPO 750, CalChoice PPO 750 GenRx,CalChoice PPO 1000, CalChoice PPO 1000 GenRx,CalChoice PPO 3000, CalChoice PPO 4000, Lumenos HSA 1800*, Lumenos HSA 2500*Healthy Support CalChoice PPO 1500 & HealthySupport CalChoice PPO 1750 GenRx

*HSA-Qualified High Deductible Health Plan

Max. percentage of employees residing out-of-stateallowed 49% (Main office must be located in California)

2-50

50% of lowest cost plan

N/A

N/A

2 2

50* N/A 2-50 No

2-50 No

◆ Those covered by another plan are NOT considered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be a group plan, Champus, Medicare or Medi-Cal * No 1 Life groups allowed † Employer contribution is 100% of employee lowest cost HMO plan or more

* Indicates a well-defined class of employees which may be selected from (i.e. carved out of) the entire group for coverage.

Employees

For Dependents

% of Total Cost:

Plan Eligibility Requirements

MINIMUM EMPLOYER CONTRIBUTION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

Carve Outs*

Wrap* Requirements

*Indicates flexibility in being offered with products of another carrier.

GROUP Can be written with another SIZE carrier's HMO, POS or EPO?

GROUP Can be written with another SIZE carrier's PPO or indemnity plan?

100% of employees not coveredby group insurance and 70% of allemployees regardless of othercoverage

†

CaliforniaChoice®

CaliforniaChoice

CaliforniaChoice

AFTER INITIAL ISSUE

ENROLLMENT GROUP SIZE

Min. # of employees Max. # of employees

No

No

Yes—coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have union coverage

2

Yes

EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?

Management/Non-management?

Union/Non-union?

Minimum group size

Does carrier underwrite and ratecarve out groups according to AB1672 guidelines?

* Over 50 only if group is SB 578 qualified. (If group has less than 50 employees, for 50% of the preceding calendar quarter or preceding calendar year)

6


*100% ◆70%

N/A N/A

Employees

Dependents

2-2 3-50

*100%

N/A N/A

Employees

Dependents

Medical Underwriting Requirements

Current Employees

TimelyAdd-ons

Enrollment Information & Requirements

Carrier's Effective Date

Premium Amount Required for 20th?

Employee Waiting Periods Available

Applications must be dated within:

Spouse/Domestic Partner Employees - 1 application or 2?

Employee Waiver Cards Required at Enrollment?

Are Telephone Interviews Conducted by Underwriting?

Must Brokers Carry Errors & Omissions Insurance?

Does Carrier Offer Open Enrollment?

DOCUMENTATION & PAYMENT INFORMATION

Quarterly/annual wage report required?

Payroll records OK if no quarterly/annual wage report?

Is a prior booklet required?

Is prior billing required?

Must submit check with initial application?

Make check payable to:

FEES

Enrollment Fee Amount

Type of Enrollment Fee

Monthly Billing Fee

DEDUCTIBLE CREDITPrior carrier deductible credit given?

4th quarter deductiblecarry-over credit given?

GROUP SIZE

ITEMS REVIEWED IN RAF CALCULATION

Rating Information

Call 800-511-0001www.choiceadmin.com†† According to the California Insurance Code “The standard

employee risk rates applied to a small employer for new business shall be in effect for no less than six months.”

Items Reviewed In RAF Calculation

Medical Conditions

Years in Business

# of Pregnancies

Virgin Group

Type of Industry

Percent of Owners

Group Size

% of COBRA Insureds

% of Family Related

Participation

Plan(s) Requested

24 HR Coverage Req'd

Employer Contribution

Bankruptcy

Gender Mix

1st of the month only

Balance Due

Min: 30 Max: 365

60 days

Use either 1 or 2 applications

Yes

No

Yes

Yes—60 days prior to anniversary

Yes None

N/A

1-8 9-20 21+$20 $25 $30

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No

*Only if any employees take PPO Dental

2-4: 1.105-50: 1.0015-50: 1.00**Groups may qualify for a 0.90. See quote for details.

12 Months

No

HMO: YesPPO: Yes

2-14 15-50 Employee Master App Medical (EmployerQuestionnaire Questions) Non Non Medical Medical

CaliforniaChoice®

CaliforniaChoice

(if enrolling separately, 2 applications required)

HMO: N/APPO: Yes**

No

RAF Increments (2-50 lives)

Rate Guarantee††

Apply Trend Factor?

Use Employee ZIPs?

**This does NOT include credit for the RX deductible

7

Call representative

Yes*

Yes*

Yes

CaliforniaChoice®


FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR CALIFORNIACHOICE REPRESENTATIVE

Provider Information CaliforniaChoice®

Benefit Summary

8


Yes —if deemed medicallynecessary by KaiserPermanente Physician

Prescriptions

If generic available, anddoctor has not indicated“dispense as written,” willmember receive a genericequivalent rather than aname brand drug?

If doctor writes “dispense as written” onprescription, is brand name available at the brand copay?

Does health plan use Rx formulary?

If medically necessary, are non-formulary drugs covered?

Mail order

*generic copay/brand namecopay/non-formulary copay if applicable

NOTE: Each HCSP HMO has their own PCP change approval process

Anthem Blue Cross HMO

Once a month – changes are effective at the beginning of thefollowing month, provided themember is not in the course oftreatment or hospitalized and nopending authorizations.

Yes

No

Yes—or you must paythe Generic copay plusthe difference in costbetween the brandname & generic equivalent

Yes

Yes

90 day supply:

Yes – referrals comedirectly from PCP

No

Yes

Health Net HMO, Elect Open Access,& Salud HMO y Más*(*only Salud network benefits shown)

Once amonth

HMO: Self: Yes— if Rapid Access provider

Yes—or you must pay brandcopay + difference in costbetween brand name &generic equivalent

Yes* — $50 non-formularycopay applies*Prior authorization may be required for certain medications

90 day supply—double retail copay

Yes

Yes

What is copay for covered non-formulary drugs?

CalChoice® HMO 15:CalChoice HMO 25:CalChoice HMO 30:CalChoice HMO 40:

CalChoice HMO 25 Value:CalChoice HMO 30 Value:CalChoice HMO 40 Value:

$40$50$50$50$50

$50

A $50 non-formulary copay applies for:CalChoice HMO 15, CalChoice HMO 25, CalChoice

HMO 25 Value, CalChoice HMO 30, CalChoiceHMO 30 Value, CalChoice HMO 40,

CalChoice HMO 40 Value, Elect Open Access, Elect Open Access 25+,

Elect Open Access 40+ and Salud HMO y Más

Generic Brand

Elect Open Access:Yes—member may selfrefer to any doctor in PPOnetwork for higher copay

CaliforniaChoice

Kaiser Permanente HMO

Generic Brand

Anytime

Yes—from KaiserPermanentePhysicians

Self: Yes—to OB/GYN andcertain other specialties(list varies by region)Express: Yes—referral directfrom physician

Yes

Yes

100 day supply—double the retail copay

No

Yes

$10$10$15$15

$20 $25 $30$30

How often can family members change theirPrimary Care Physician?(PCP)

Can family memberseach choose a PCP from a differentIPA/Medical Group?

Do plans have these types of programs to speed the specialist referral process in network: Self referral?Express referral?

Is there an Out-of-Network benefit?

Yes* — non-formularycopay applies*Prior authorization may be required for certain medications

CalChoice HMO 15:CalChoice HMO 25:CalChoice HMO 30:CalChoice HMO 40:


$10/$40/$80$15/$60/$100$15/$60/$100$20/$60/$100$15/$60/$100

$15/$60/$100

Aetna

Anytime

Yes

No

Yes

Yes

Yes

90 day supply:

No

$50$50$50$50$60$60$60

Yes* — non-formularycopay applies*Prior authorization maybe required for certainmedications

20/40/10030/60/10030/60/10040/60/10040/80/12040/80/12040/80/120

The Brand Rx deductiblewill apply, excludingCalChoice HMO 15

HMO

FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR CALIFORNIACHOICE REPRESENTATIVE

SharpHealth Plan

Once a month

Yes

Self: Yes—availablethrough medical group(some medical groupsoffer direct access tocertain specialists)

Yes

Yes

Yes* — non-formularycopay applies *Prior authorization may be required for certain medications

90 day supply—double the30-day retail copay

non-formulary:Call your

CaliforniaChoice representative

No

Yes

Generic Brand

Double theformulary brand

copay

Prescriptions



Anytime—in a PPO, you do nothave to choose a PCP

Yes—each family member canmake their own physician choice

Yes – in a PPO, you can choose anyphysician

Yes—Negotiated Fee Schedule

PPO 750, PPO 1000, PPO 3000, PPO 4000, Lumenos HSA1800 & 2500 & PPO 1500: Yes—or you must pay the Genericcopay plus the difference in cost between the brand name &generic equivalent PPO 750 GenRx, PPO 1000 GenRx & PPO 1750 GenRxprescription drug plan includes coverage for drugs on theGenRx prescription Drug Formulary only

Yes

Participating Pharmacy: $50 Non-Participating Pharmacy: 50% of Maximum allowedamount* PPO 750 GenRx, PPO 1000 GenRx, PPO 1500 & PPO 1750GenRx: Not covered

The brand deductible will apply:

No

WesternHealth Advantage

Yes—but only fromnetwork physicians

Yes—Advantage Referral Program allowsPCP referral to most specialists in the WHAnetwork who participatein the Advantage ReferralProgram

Yes—or you must paythe brand copay plusthe difference in costbetween the brandname and genericequivalent

Yes

90 day supply—

Yes

Once a month—changes areeffective at beginning of followingmonth, provided the member isnot in the course of treatment orhospitalized and no pendingauthorizations

CaliforniaChoice®

CaliforniaChoice

PPO 750, PPO 1000, PPO 3000, PPO 4000, Lumenos HSA1800 & 2500 & PPO 1500: No—member will have to pay thegeneric copay plus the difference in cost between genericand brand PPO 750 GenRx, PPO 1000 GenRx & PPO 1750 GenRxprescription drug plan includes coverage for drugs on theGenRx prescription Drug Formulary only

PPO 750 - $150 PPO 1000 - $200 PPO 3000 - $250 PPO 4000 - $250 Lumenos HSA 1800 - subject to medical deductible Lumenos HSA 2500 - subject to medical deductible PPO 1500 - $500

Benefit Summary

90 day supply: $15/$60/$100Non-Participating Pharmacy: Not CoveredNo Non-Formulary Benefits for GenRxThe brand deductible will apply:

$35 $50 $50$50

CalChoice HMO 40 Value $50


CalChoice HMO 15: $25/$50/$88CalChoice HMO 25: $38/$75/$125CalChoice HMO 30: $38/$75/$125CalChoice HMO 40: $50/$75/$125

CalChoice HMO 40 Value: $50/$75/$125

Yes* — non-formularycopay applies *Prior authorization may be required for certain medications

9

Anthem Blue Cross Life and HealthInsurance Company

PPO 750 - $150PPO 1000 - $200PPO 3000 - $250PPO 4000 - $250Lumenos HSA 1800 - subject to medical deductibleLumenos HSA 2500 - subject to medical deductible

PPO


If doctor writes “dispense as written” onprescription, is brand name available at the brand copay?



Mail order


CalChoice® HMO 15:CalChoice HMO 25:CalChoice HMO 30:CalChoice HMO 40:


How often can family members change theirPrimary Care Physician?(PCP)

Can family memberseach choose a PCP from a differentIPA/Medical Group?





CalChoice HMO 15:CalChoice HMO 25:CalChoice HMO 30:CalChoice HMO 40:


Diabetic Benefits

Benefit Summary

CaliforniaChoice®

10


Are self-injectable drugs(other than insulin) covered under thePrescription Drug benefitor Medical Benefit?

Anthem BlueCross HMO

Health Net HMO, Elect Open Access,& Salud HMO y Más*(*only Salud network benefits shown)

Self-Injectable Drug Benefits CaliforniaChoice


Insulin

Is pre-authorizationrequired?

Must self-injectables(other than insulin) bepurchased via the carrier-contracted mailorder RX vendor?

Needles & Syringes

Glucose Monitor†

Chem-Strips and/orTesting Agents

Insulin Pump†

Insulin Pump Supplies

May depend on themedication. CallPharmacy Services at 800-700-2533 to confirm

Some medicationsand/or dosagesmay requireprior authorization

Certain drugs must go through mail-order provider.Call Pharmacy Services at 800-700-2533 to confirm

PrescriptionDrug Benefit


Covered as Medical Supplies ratherthan Prescription Drug Benefit:All other monitors covered at: CalChoice HMO 15 - 90%CalChoice HMO 25 - 80%CalChoice HMO 25 Value - 80%CalChoice HMO 30 - 80%CalChoice HMO 30 Value - 80%CalChoice HMO 40 - 80%CalChoice HMO 40 Value - 80%Elect Open Access 25 - 80% Elect Open Access 25+ - 80% Elect Open Access 40+ - 80%Salud HMO y Más - 80%


Covered at:CalChoice HMO 15 - 90%CalChoice HMO 25 - 80%CalChoice HMO 25 Value - 80%CalChoice HMO 30 - 80%CalChoice HMO 30 Value - 80%CalChoice HMO 40 - 80%CalChoice HMO 40 Value - 80%Elect Open Access 25 - 80%Elect Open Access 25+ - 80%Elect Open Access 40+ - 80%Salud HMO y Más - 80%

Covered at:CalChoice HMO 15 - 90%CalChoice HMO 25 - 80%CalChoice HMO 25 Value - 80%CalChoice HMO 30 - 80%CalChoice HMO 30 Value - 80%CalChoice HMO 40 - 80%Cal Choice HMO 40 Value - 80%Elect Open Access 25 - 80%Elect Open Access 25+ - 80%Elect Open Access 40+ - 80%Salud HMO y Más - 80%

Medical Benefit

Yes

No—use doctor'scontracted vendor



Durable MedicalEquipment BenefitCalChoice HMO 15 - 90% CalChoice HMO 25 - 70% CalChoice HMO 30 - 50% CalChoice HMO 40 - 50%

Up to $2500 max./calendar year

Blood test strips are covered under Durable Medical Equipment;Urine test strips are covered under Prescription Drug Benefit

Durable MedicalEquipment Benefit



Must be prescribedby a planphysician

Must use planpharmacies(including affiliatedpharmacies)

HMOAre the following items covered under the Prescription DrugBenefit, Durable MedicalEquipment Benefit orDiabetes Care Benefit of the member’s selected plan design?



Free Glucometer Program for certain manufacturers;otherwise, covered underDurable Medical Equipment:

CalChoice HMO 15—90%CalChoice HMO 25—70%CalChoice HMO 30—50%CalChoice HMO 40—50%CalChoice HMO 25 Value–50%CalChoice HMO 40 Value–50%

(Blood Test Strips)Covered under thePrescription Drug Benefits



† Vendors for Diabetes Equipment:

Benefits are typically covered under the pharmacy benefit withparticipating pharmacies. Health Netwill only cover certain machines.

PendingPlease see carrierwebsite for list ofproviders

Aetna

Medical Benefit


Most drugs requirepurchase throughAetna's Specialty Rxprogram

Purchased via contractedpharmacy, Rx copays willapply

Covered as a medical supplythrough a contracted medicalsupply company, no membercost share applies. If purchasedvia pharmacy with valid Rx, thenRx copays apply

Free Glucometer Program for certain manufacturers;otherwise, covered underDurable Medical Equipment:

CalChoice® HMO 15—90%CalChoice HMO 25—70%CalChoice HMO 30—50%CalChoice HMO 40—50%CalChoice HMO 25 Value–50%CalChoice HMO 30 Value–50%CalChoice HMO 40 Value–50%

Purchased viacontracted pharmacy,Rx copays will apply

Covered as medicalsupply through acontracted medicalsupply company, nomember cost shareapplies

Covered as a medicalsupply through acontracted medicalsupply company, nomember cost shareapplies

Please see carrierwebsite for list ofproviders

SharpHealth Plan


Insulin



Needles & Syringes

Glucose Monitor†


Insulin Pump†



Prescription Drug Benefit

Durable MedicalEquipment BenefitCalChoice HMO 15 - 90%CalChoice HMO 25 - 70%CalChoice HMO 30 - 50%CalChoice HMO 40 - 50%




May depend onmedication


No—mail ordernot required

Diabetic Benefits

Benefit Summary

Anthem Blue Cross Life and HealthInsurance Company

WesternHealth Advantage

CaliforniaChoice®

Self-Injectable Drug Benefits CaliforniaChoice



Free Glucometer Program for certain manufacturers;otherwise, covered underDurable Medical Equipment

In-Network: 50%Out-of-Network: 50%

(Blood Test Strips) Covered underthe Prescription Drug Benefits



May depend on the medication. Call PharmacyServices at 800-700-2533 to confirm


Certain drugs must go through mail-order provider.Call Pharmacy Services at 800-700-2533 to confirm



Durable MedicalEquipment BenefitCalChoice HMO 15 - 90%CalChoice HMO 25 - 70%CalChoice HMO 30 - 50%CalChoice HMO 40 - 50%CalChoice HMO 40 Value - 50%

Up to $2500 max./calendaryear


Durable MedicalEquipment BenefitCalChoice HMO 15 - 90%CalChoice HMO 25 - 70%CalChoice HMO 30 - 50%CalChoice HMO 40 - 50%CalChoice HMO 40 Value - 50%

Up to $2500 max./calendaryear


Medical Benefit

Yes

Depends onmedical group

PPOAre the following items covered under the Prescription DrugBenefit, Durable MedicalEquipment Benefit orDiabetes Care Benefit of the member’s selected plan design?

11

ADSAdvanced Diabetes Supply 390 Oak Avenue, Suite "N"Carlsbad, CA 92008800-730-9887Edgepark1810 Summit Commerce ParkTwinsburg, OH 44087800-321-0591

Please see carrierwebsite for list ofproviders

Contract is withMedical Group.See PCP



MEDICAL

12

GENERIC VS. BRAND NAME

If generic available, and doctor has not indicated“dispense as written,” will member receive a genericequivalent rather than a brand name drug?


If doctor writes “dispense as written” on prescription, is brand name available at the brandcopay amount?


Prescriptions

FORMULARY VS. NON-FORMULARY

Does carrier use Rx formulary?Refer to summary on pages 8-9

Are non-formulary drugs available?Refer to summary on pages 8-9

MAIL ORDER - 90 DAY SUPPLYRefer to summary on pages 8-9

Are oral contraceptives covered?Yes—subject to the Drug Formulary for the HealthCare Service Plan selected by member

CaliforniaChoice

Discounts, Awards & Other Value-Added Benefits CaliforniaChoice

www.choiceadmin.com

KEY TO HEALTH CARE SERVICE PLANS OFFERING LISTED PROGRAM:

AE AetnaABC Anthem Blue CrossHN Health NetKP Kaiser PermanenteSH Sharp Health PlanWH Western Health Advantage

* All CaliforniaChoice® medical members are eligible for discounts on eye exams, lenses, frames, and contacts through the Vision OneEye Care Program administered by Cole Managed Vision/EyeMed Vision Care.

1 Discounts of frames and lenses available through Kaiser Permanente facilities.

2 Discounts on vitamins and herbal supplements available through the “Affinity Program” which links Kaiser Permanente members toHealthy Roads.

3 Member must use a Kaiser Permanente weight loss program.

Which health care plans offer these discounts, awards and other value-added benefits?Eyewear & lenses discount ......................................................................................................................AE, ABC, HN, KP 1

Health club membership or fitness equipment/sporting goods discount ........................................AE, ABC, HN, KP, WHHealth literature, telephone tapes and/or videos (no charge)......................................................................AE, HN, KP, SH available in the following languages: SpanishPersonalized, dynamic online tools on health information......................................................................................AE, ABCHome childproofing products discount ..................................................................................................................ABC, HNInfant car seat: discount ............................................................................................................................................................HN awarded upon prenatal class completion ..........................................................................................................HNNurses 24 hour hotline ........................................................................................................................AE, ABC, HN, KP, SHVitamins and/or herbal supplements discount ................................................................................AE, ABC, HN, KP 2, SHWeight control program discount ....................................................................................................AE, ABC, HN, KP 3, SH

13

Colusa

Calaveras Marin

Monterey

Sacra- mento

Alameda

Alpine Amador

Butte

Contra Costa

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Madera

Mariposa

Mendocino

Merced

Modoc

Mono

Napa

Nevada

Orange

Placer

Plumas

Riverside

San Benito

San Bernardino

San Diego

San Francisco

San Joaquin

San Luis

Obispo

San Mateo

Santa Barbara

Santa Clara

Santa Cruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sut- ter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo

Yuba Lakke La


HMO & PPO Counties Plan may not be available in all ZIP Codes within county. Check with your CaliforniaChoice 51+ representative to confirm if coverage is available for your group location.


MEDICAL

14

CaliforniaChoice®Carrier Contact Information

Member SupportCaliforniaChoice 51+ Customer Service Center 866-451-7587Health Net 800-361-3366Kaiser Permanente

English 800-464-4000Spanish 800-788-0616

Western Health Advantage 888-563-2250


Internet Support www.calchoiceplus.com


Broker Services & Commissions 714-567-4390

[email protected]

Broker of Record Changes Fax 714-972-7368

Adds/Terms Fax 714-664-1711



To contact by mail, or for payment submission: CaliforniaChoice 51+

721 South Parker, Suite 200Orange, CA 92868


CaliforniaChoice 51+

www.choiceadmin.com

Is Workers' Comp required on corporate officers, partners and sole proprietors?No

Is on-the-job covered for corporate officers, partners and sole proprietors?Yes

Is there a premium adjustmentfor 24 hour coverage?No

MEDICAL

15

How often can members change their Primary Care Physician (PCP)?Varies by plan type. Contact yourCaliforniaChoice 51+ representative

Can family members each choose a PCP from a differentIPA/Medical Group?Varies by plan type. Contact yourCaliforniaChoice 51+ representative

HMO


Products Offered Provider InformationCaliforniaChoice 51+

24 HOUR COVERAGE



Express referral available?Varies by plan type. Contact yourCaliforniaChoice 51+ representative

Varies by plan type. Contact yourCaliforniaChoice 51+ representative

CalChoice® 51+ HMO 15CalChoice 51+ HMO 15 ValueCalChoice 51+ HMO 25CalChoice 51+ HMO 20/$500 ValueCalChoice 51+ HMO 25 ValueCalChoice 51+ HMO 40CalChoice 51+ HMO 40 ValueElect Open AccessSalud HMO y Más

PPO

CalChoice 51+ PPO 250CalChoice 51+ PPO 500CalChoice 51+ PPO 1000CalChoice 51+ PPO 1500

SELECTION

NETWORKS

PPO plan availability based on group eligibility and may be subject to change

Prepaid

FDH 100Prepaid 1000Prepaid 3000

PPO

EPO 3000EPO 3500EPO 4000EPO 5000

DENTAL

Vision DiscountsVoluntary Vision

VISION

Term Life & AD&D

LIFE

www.choiceadmin.com

Products Offered CaliforniaChoice 51+


HSA-Compatible HMOHDHP 1500HSA 1800


INDEMNITY

Flex Net (Out of Area Only)

HSA-Compatible PPOHSA 1500HSA 2000

Ancillary CaliforniaChoice 51+

Health Net HMOHealth Net Silver HMOKaiser Permanente HMO

Western Health Advantage HMOHealth Net PPO

Maximum Choice For EmployeesEach employee's health care needs are different. The CaliforniaChoice 51+program provides employees the maximum choice in meeting those needswith these health plans—all within one program:

Multi Option (Mix And Match) CaliforniaChoice 51+

PLEASE NOTE: Not all health plans are available in all areas.

16

40* 40

No max. No max.


Are Commission-Only employees allowed?

Are 1099 employees allowed?

Are employees covered if traveling out of USA?

Is coverage available for out-of-state employees?

Max. percentage of employees residing out-of-stateallowed


EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Not allowed

Management/Non-management?Not allowed

Union/Non-union?Not allowed

Minimum group sizeN/A



Carve Outs*

Wrap* Requirements



No

No

Yes—out-of-network or BlueCard (for emergencies only)

Yes

49%

N/A No

N/A No



Contributory

Non-Contributory

Employees

Dependents


Employees

For Dependents

% of Total Cost:


PARTICIPATION

Min. # of employees

Max. # of employees

GROUP SIZE

GROUP SIZE

100%

100%


N/A

N/A

51-199


* 70% of eligible employees must enroll with a minimum of 40.

AFTER INITIAL ISSUE

70% (those covered by another group plan, Champus,Medicare or Medi-Cal are not considered eligible in

calculating group participation)

51-199

N/A

Employees

Dependents


17


N/A

Yes—1st of the month after date of hire—1 year max.

30 days

Yes

No

Yes



Current Employees

TimelyAdd-ons

Group Size

Rate Guarantee

Apply Trend Factor?

Use Employee ZIPs?







Employee Waiver Cards Required at enrollment?




DOCUMENTATION & PAYMENT INFORMATIONQuarterly/Annual wage statement required?






FEES



Monthly Administration Fee



GROUP SIZE51-199

Rating Information

Items Reviewed In Underwriting

Medical Conditions

Years in Business

# of Pregnancies

Virgin Group

Type of Industry

Percent of Owners

Group Size

% of COBRA Insureds

% of Family Related

Participation

Plan(s) Requested



Bankruptcy

Gender Mix

None

N/A

N/A

No

No

No

No

No

No

Yes

No

No

Yes

No

No

No

No

No

HMO: N/A PPO: Yes (This does notinclude credit for RxDeductible)

No

Non-Medical

Yes

Yes, previous 3 monthsrequired

Yes—only if any employeestake PPO Dental

Yes—only if any employeestake PPO Dental

Yes


Use either 1 or 2 applications (if enrolling separately, 2 applicationsrequired)

Non-Medical

51-199

12 months

Yes

Yes




FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR CALIFORNIACHOICE 51+ REPRESENTATIVE


Prescriptions


If doctor writes “dispense as written” on prescription, is brand name available at the brand copay?



Mail order


Health Net HMO,Elect Open Access andSalud HMO y MásOnce a month

Yes

No

Yes—or you must pay thebrand copay plus thedifference in cost betweenthe brand name & genericequivalent

Yes

Yes

90 day supply:

Yes—some Rapid AccessProviders offer expressreferrals

No

Yes

Kaiser Permanente HMO and HDHP

Yes—referrals come directly from PCP; no otherapproval is needed

Yes

Yes—HMO & HDHP: If deemed medically necessary by Kaiser Permanente Physician. HDHP - Applies to plan deductible, then $0 copay.

Yes—but only from HealthPlan Physicians

Yes

Prescription DrugBenefits

CalChoice 51+ HMO 15

CalChoice 51+ HMO 15 Value





Elect Open Access

Salud HMO y Más



Western HealthAdvantage HMOand HSA

How often can familymembers change theirPrimary Care Physician?(PCP)

Can family memberseach choose a PCP froma different IPA/MedicalGroup?



Yes—$50 copay. Prior authorization may be required.

HMO

CalChoice 51+ HMO 15 $20/$40/$100

CalChoice 51+ HMO 15 Value $30/$60/$100 $150 Brand Ded

CalChoice 51+ HMO 25 $30/$50/$100


CalChoice 51+ HMO 40 $40/$70/$100


Elect Open Access $30/$50/$100

Salud HMO y Más $30/$50/$100

Generic/Brand/Nonform

Anytime

$10

$15

$15

$20

$20

$20

$15

$15


CalChoice 51+HMO 20/$500 Value



CalChoice 51+ HDHP 1500

$10

$10

$10

$15

$0*

$20

$100 ded-$30

$25

$30

$0*

*After deductible




CalChoice 51+ HSA 1800

Generic Brand

$10

$15

$20

$0*

$20

$25

$35

$0*

No

Yes

Yes—Advantage ReferralProgram allows PCP to refermember to any specialist in theWHA network who participatesin the Advantage ReferralProgram

Yes—or you must pay the brand copay plus the difference in cost between the brand name & genericequivalent

Yes—HMO $50 copay. HSA - Applies to plan deductible,then $0 copay. Prior authorizationmay be required.

Yes - but only from HealthPlan Physicians

Yes

Once a month - changes are effective atthe beginning of the following month,provided the member is not in thecourse of treatment or hospitalized andno pending authorizations

*After deductible

Up to 100 day supply:

CalChoice 51+ HMO 15 $20/$40

CalChoice 51+ HMO 20/$500 Value $10/$30



CalChoice 51+ HDHP 1500 Applies to plan deductible, then $0 copay

No mail order benefit for Non-Formulary

Generic/Brand

90 day supply:

CalChoice 51+ HMO 15 $25/$50/$125

CalChoice 51+ HMO 25 $38/$63/$125

CalChoice 51+ HMO 40 $50/$88/$125

CalChoice 51+ Applies to plan HSA 1800 deductible, then $0 copay

Generic/Brand/Nonform

Generic BrandGeneric Brand

$20

$150 Ded-$30

$25

$200 Ded-$40

$35

$250 Ded-$40

$25

$25

Benefit Summary


18

BENEFIT SUMMARYBENEFIT

SUMMARYProvider Information CaliforniaChoice 51+

Benefit Summary

Prescriptions

FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR CALIFORNIACHOICE 51+ REPRESENTATIVE

Health Net PPO& Indemnity

Anytime—In a PPO or Indemnity Plan, you do nothave to choose a PCP

Yes—Each family member can make their ownphysician choice

Yes

Yes—or you must pay the brand copay plus thedifference between the cost of the brand name & generic

Yes—Except for Flex Net (out-of-state only), the copay isthe same as it is for generic medications.

Yes

Yes—In a PPO or Indemnity Plan, you don't haveto go through a specialist referral process


Yes

HMO 15 $25/$50/$125 HMO 25 38/$63/$125 HMO 40 $50/$88/$125 HSA 1800 Applies to plan deductible, then $0 copay

CalChoice 51+ PPO 250 CalChoice 51+ PPO 500CalChoice 51+ PPO 1000CalChoice 51+ PPO 1500CalChoice 51+ HSA 1500




If medically necessary, arenon-formulary drugs covered?

Mail order

Prescription DrugBenefits





PPO

Generic Brand

$10$10$10$10$10 after ded.$15 after ded.20%

CalChoice 51+ PPO 250CalChoice 51+ PPO 500CalChoice 51+ PPO 1000CalChoice 51+ PPO 1500CalChoice 51+ HSA 1500*CalChoice 51+ HSA 2000**Flex Net

Participating Pharmacy:

$20$20$20$20$25 after ded.$30 after ded.20%†

Brand Ded.

N/A$100$150$150See below*See below**$75 applies toall Rx's

* HSA 1500 - All prescription drug benefits are subject to combined medical and prescription drug deductible of $1500 per individual.** HSA 2000 - All prescription drug benefits are subject to combined medical and prescription drug deductible of $2000 per individual.† Member must try and fill with generic first. If the member opts for brand without first trying the generic an additional ancillary copay may

apply.

Generic Brand

$10 + 50%$10 + 50%$10 + 50%$10 + 50%$10 + 50% after ded.$15 + 50% after ded.Not covered

Non-Participating Pharmacy:

$20 + 50%†

$20 + 50%†

$20 + 50%†

$20 + 50%†

$25 + 50% after ded$30 + 50% after dedNot covered

Brand Ded.

N/A$100†

$150$150See below*See below**Not covered

Generic Brand

$20$20$20$20$20$30

CalChoice 51+ PPO 250CalChoice 51+ PPO 500CalChoice 51+ PPO 1000CalChoice 51+ PPO 1500CalChoice 51+ HSA 1500*CalChoice 51+ HSA 2000**

$40$40$40$40$50$60

Brand Ded.

$70$70 - A separate $100 per individual deductible applies to Formulary & Non-Formulary Brand Drugs$70 - A separate $150 per individual deductible applies to Formulary & Non-Formulary Brand Drugs$70 - A separate $150 per individual deductible applies to Formulary & Non-Formulary Brand Drugs$100 $100

Flex Net - Members are allowed to use the Rx by mail program, however they are not given any type of discount. Therefore, it is their 20% coinsurance x 3 months

* HSA 1500 - All prescription drug benefits are subject to combined medical and prescription drug deductible of $1500 per individual. The submission of prescription drug claim is required for reimbursement of all outpatient prescription drugs.

** HSA 2000 - All prescription drug benefits are subject to combined medical and prescription drug deductible of $2000 per individual.


19

Diabetic Benefits

Are self-injectable drugs(other than insulin)covered under thePrescription Drug benefitor Medical Benefit?

Benefit Summary

Self-Injectable Drug Benefits



Insulin



Needles & Syringes

Glucose Monitor†


Insulin Pump†


Medical Benefit

Yes

No - use doctor's contracted vendor

Covered under thePrescription Drug Benefit


Covered as Durable Medical Equipment,rather than Prescription Drug Benefit:

CalChoice 51+ HMO 15 - 100%CalChoice 51+ HMO 20/$500 Value - 80%CalChoice 51+ HMO 25 - 80%CalChoice 51+ HMO 40 - 50%

HDHP - Covered at $0 copay, after Plandeductible has been met

Blood Test Strips are covered asDurable Medical Equipment.Urine Test Strips are covered under the Prescription Drug Benefit.

Covered as DurableMedical Equipment, ratherthan Prescription DrugBenefit

Covered as Durable MedicalEquipment rather thanPrescription Drug Benefit


Must be prescribed by a plan physician

Must use plan pharmacies(including affiliatedpharmacies)


Covered under the Prescription Drug Benefit

Covered as Durable Medical Equipment, ratherthan Prescription Drug Benefit:

CalChoice 51+ HMO 15 - 90%CalChoice 51+ HMO 25 - 70%CalChoice 51+ HMO 40 - 50%Up to max $2500/year

HSA - $0 copay, after Plan deductible has been met

HMO - Covered under thePrescription Drug BenefitHSA - Covered as Durable MedicalEquipment rather than PrescriptionDrug Benefit

Covered as DurableMedical Equipment, ratherthan Prescription DrugBenefit

Covered as Durable MedicalEquipment rather thanPrescription Drug Benefit

Medical Benefit

Yes

Depends on medicalgroup

HMOAre the following items covered under the Prescription DrugBenefit, Durable MedicalEquipment Benefit orDiabetes Care Benefit of the member’s selected plan design?



Covered as Medical Supplies, rather than Prescription Drug Benefit:

CalChoice 51+ HMO 15 - 90%CalChoice 51+ HMO 15 Value - 85%CalChoice 51+ HMO 25 - 80%CalChoice 51+ HMO 25 Value - 80%CalChoice 51+ HMO 40 - 80%CalChoice 51+ HMO 40 Value - 80%Elect Open Access - 80%Salud HMO y Más - 80%


Covered as Durable MedicalEquipment, rather thanPrescription Drug Benefit

Covered as DurableMedical Equipmentrather than PrescriptionDrug Benefit


Health Net HMO,Elect Open Access andSalud HMO y Más

Kaiser Permanente HMO and HDHP

Western HealthAdvantage HMOand HSA


20

Pending Contract is with MedicalGroup. See PCP

Benefits are typically covered under the pharmacy benefit withparticipating pharmacies. Health Netwill only cover certain machines.

Covered as Durable Medical Equipment (Medical Deductible applies)CalChoice 51+PPO 250 - In-Network: 90%, Out-of-Network: 70%CalChoice 51+PPO 500 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+PPO 1000 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+PPO 1500 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+HSA 1500 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+HSA 2000 - In-Network: 80%, Out-of-Network: 50%Flex Net - 80%




Covered as Durable Medical Equipment (Medical Deductible applies)CalChoice 51+ PPO 250 - In-Network: 90%, Out-of-Network: 70%CalChoice 51+ PPO 500 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+ PPO 1000 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+ PPO 1500 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+ HSA 1500 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+ HSA 2000 - In-Network: 80%, Out-of-Network: 50%Flex Net - 80%

Diabetic Benefits

Benefit Summary



Self-Injectable Drug Benefits CaliforniaChoice 51+


Yes

Certain drugs must gothrough contracted vendor

Are self-injectable drugs(other than insulin)covered under thePrescription Drug benefitor Medical Benefit?

Insulin



Needles & Syringes

Glucose Monitor†


Insulin Pump†


Are the following items covered under the Prescription DrugBenefit, Durable MedicalEquipment Benefit orDiabetes Care Benefit of the member’s selected plan design?


Covered as Medical Supplies, rather than Prescription Drug Benefit:CalChoice 51+ PPO 250 - In-Network: 90%, Out-of-Network: 70%CalChoice 51+ PPO 500 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+ PPO 1000 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+ PPO 1500 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+ HSA 1500 - In-Network: 80%, Out-of-Network: 60%CalChoice 51+ HSA 2000 - In-Network: 80%, Out-of-Network: 50%Flex Net - 80%

Health Net PPO& Indemnity

PPO


21

Benefits are typically covered under the pharmacy benefit with participatingpharmacies. Health Net will only cover certain machines.

MEDICAL






Prescriptions

FORMULARY VS. NON-FORMULARY

Does carrier use Rx formulary?Refer to summary on pages 18-19

Are non-formulary drugs available?Refer to summary on pages 18-19

MAIL ORDER - 90 DAY SUPPLYRefer to summary on pages 18-19

Are oral contraceptives covered?Yes—subject to the Drug Formulary for the HealthCare Service Plan selected by member


KEY TO HEALTH CARE SERVICE PLANS OFFERING LISTED PROGRAM:

ABC Anthem Blue CrossHN Health NetKP Kaiser PermanenteSH Sharp Health PlanWH Western Health Advantage

* All CaliforniaChoice 51+ medical members are eligible for discounts on eye exams, lenses, frames, and contacts through the VisionOne Eye Care Program administered by EyeMed Vision Care.


2 Discounts on vitamins and herbal supplements available through the “Affinity Program” which links Kaiser Permanente members toHealthy Roads


Which health care plans offer these discounts, awards and other value-added benefits?Eyewear & lenses discount ......................................................................................................................................HN, KP 1

Health club membership or fitness equipment/sporting goods discount ........................................................HN, KP, WHHealth literature, telephone tapes and/or videos (no charge) ..................................................................................HN, KP available in the following languages: SpanishHome childproofing products discount ..........................................................................................................................HNInfant car seat: discount ............................................................................................................................................................HN awarded upon prenatal class completion ..........................................................................................................HNNurses 24 hour hotline ..............................................................................................................................................HN, KPVitamins and/or herbal supplements discount ........................................................................................................HN, KP2

Weight control program discount ............................................................................................................................HN, KP3

Discounts, Awards & Other Value-Added Benefits CaliforniaChoice 51+

www.choiceadmin.com

22

Colusa

Calaveras Marin

Monterey

Sacra- mento

Alameda

Alpine Amador

Butte

Contra Costa

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Madera

Mariposa

Mendocino

Merced

Modoc

Mono

Napa

Nevada

Orange

Placer

Plumas

Riverside

San Benito

San Bernardino

San Diego

San Francisco

San Joaquin

San Luis

Obispo

San Mateo

Santa Barbara

Santa Clara

Santa Cruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sut- ter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo

Yuba Colusa

CalaverasMarin

Monterey

Sacra-mento

Alameda

Alpine

Butte

ContraCosta

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Madera

Mariposa

Mendocino

Merced

Modoc

Mono

Napa

Nevada

Orange

Placer

Plumas

Riverside

SanBenito

San Bernardino

San Diego

San Francisco

SanJoaquin

SanLuis

Obispo

SanMateo

SantaBarbara

Santa Clara

SantaCruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sut-ter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo

Yuba


HMO & PPO Counties

Plan may not be available in all ZIP Codes within county. Check with your HSA California representative to confirm if coverage is available for your group location.

23

www.choiceadmin.com


MEDICAL

24

HSA California®

www.choiceadmin.com

Carrier Contact Information

Member SupportHSA California ® Customer Service 866-251-4718Health Net 800-361-3366Western Health Advantage 888-563-2250Kaiser Permanente

English 800-464-4000Spanish 800-788-0616


Internet Support www.hsacalifornia.com


Broker Services &Commissions Fax 714-972-7368



Missing BOR Changes Fax 714-972-7368

To contact by mail or for payment submissions HSA California

721 South Parker, Ste. 200Orange, CA 92868


MEDICAL

HSA California®

Is Workers' Comp required oncorporate officers, partners and sole proprietors?

Is on-the-job covered for corporate officers, partners and sole proprietors?

Is there a premium adjustment for24 hour coverage?

How often can members change their Primary Care Physician (PCP)?Refer to summary on page 28

Can family members each choose a PCP from a differentIPA/Medical Group?Refer to summary on page 28

Maximum Choice For EmployeesEach employee's health care needs are different. The HSA Californiaprogram provides employees the maximum choice in meeting those needs with these health plans—all within one program:

HMO

Available

Buy-up

Discount or Buy-up

Not Available

Varies by HCSP

2-50


No

No

Yes

PLEASE NOTE: Not all health plans are available in all areas

Products Offered

Multi Option (Mix And Match)

OptionalBenefits

GROUP SIZE


HSA California

HSA California®

HSA California

LIFE

DENTAL

VISION

INFERTILITY

MASSAGE THERAPY

Health Net PPOKaiser Permanente HMOWestern Health Advantage HMO

24 HOUR COVERAGE



Express referral available?Varies by Health Care Service Plan (See summary on page 28)

Varies by Health Care Service Plan (See summary on page 28)

HMO 1800HMO 2200HMO 2600

HMO 2800B

PPOPPO 2500PPO 3500PPO 4500

SELECTION

NETWORKS

25


*100%

N/A N/A

*100% ◆70%

N/A N/A


Employees

Dependents


Are Commission employees allowed? Yes—if on quarterly/annual wage report and showing at least minimum wages and withholdings



Is coverage available for out-of-state employees? Yes*— PPO 2500, PPO 3500, PPO 4500

*Except for employees in Hawaii

Max. percentage of employees residing out-of-stateallowed

49% (Main office must be located in California)

2-50


N/A

N/A

2 2

50* N/A 2-50 No

2-50 No




Carve Outs*

Wrap* Requirements




100% of employees not coveredby group insurance and 70% ofall employees regardless of othercoverage

HSA California®

HSA California

HSA California

AFTER INITIAL ISSUE



No

No

Yes—coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have union coverage

2

Yes



Union/Non-union?

Minimum group size

Does carrier underwrite and ratecarve out groups according to AB1672 guidelines?


26


GROUP SIZEPARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

†

Employees

For Dependents

% of Total Cost:

2-2 3-50

Employees

Dependents


Current Employees

TimelyAdd-ons











FEES



Monthly Billing Fee



GROUP SIZE

ITEMS REVIEWED IN RAF CALCULATION

Rating Information

†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”


Medical Conditions

Years in Business

# of Pregnancies

Virgin Group

Type of Industry

Percent of Owners

Group Size

% of COBRA Insureds

% of Family Related

Participation

Plan(s) Requested



Bankruptcy

Gender Mix


Balance Due

Min: 30 Max: 365

60 days


Yes

No

Yes


None

N/A

1-8 9-20 21+$20 $25 $30

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No

2-4: 1.105-50: 1.0015-50: 1.00**Groups may qualify for a 0.90.See quote for details.

12 Months

No

HMO: YesPPO: Yes


HSA California®

HSA California


HMO: N/APPO: Yes**

No

RAF Increments (2-50 lives)


Apply Trend Factor?

Use Employee ZIPs?

**This does NOT include credit for the RX deductible

27








Yes


Call representative

Yes*

Yes*

Yes

HSA California®


Call 800-511-0001www.choiceadmin.com


Prescriptions





Mail order

Benefit Summary



FOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR HSA CALIFORNIA® REPRESENTATIVE


HSA California®

HSA California


HMO 2200$10 Generic$20 BrandHMO 2600$10 Generic$30 Brand

Anytime

Yes—but only PlanPhysicians

Yes—referrals comedirectly from PCP; no other approval is needed

Yes

Yes

Yes

No

Yes





HMO 2200$20 Generic$40 BrandHMO 2600$20 Generic$60 Brand

Western HealthAdvantage HMO

Yes

Yes—Advantage ReferralProgram allows PCP to refer amember to a specialist who participates in WHA’sAdvantage Referral program

Yes—or you must paythe brand copay plusthe difference in costbetween brand name& generic equivalent

Yes

No

Yes

HMO 1800No Charge

HMO 2800B$25 Generic$75 Brand

$125 Non-Formulary

HMO 1800No Charge

HMO 2800B$50 Copay

Yes* — non-formulary copayapplies*Prior authorization may be requiredfor certain medications

Health NetPPO

Anytime—in a PPO,you do not have tochoose a PCP

Yes—each familymember can make theirown physician choice

Yes—in a PPO, youdon't have to gothrough a specialistreferral process

Yes—or you must paythe brand copay plusthe differencebetween the cost of the brand name & generic

Yes

Yes

Yes

Participating Pharmacy$30 Generic$60 Brand

$100 Non-Formulary

Non-ParticipatingPharmacy

Not Covered

Participating Pharmacy$50 Non-Formulary

Non-Participating Pharmacy50%

Prior authorization may berequired for certain medications

Yes

28

Once a month—changes are effectiveat beginning of following month,provided the member is not in thecourse of treatment or hospitalized andno pending authorizations


Benefit SummaryFOR DETAILED BENEFIT INFO, LIMITATIONS AND EXCLUSIONS, PLEASE REFER TO

BOOKLET CERTIFICATE/EVIDENCE OF COVERAGE, OR CONTACT YOUR HSA CALIFORNIA® REPRESENTATIVE



Are the following items covered under the Prescription Drug Benefit or the Durable MedicalEquipment Benefit of themember’s selected plan design?

Insulin



Needles & Syringes

Glucose Monitor†


Insulin Pump†


Diabetic Benefits HSA California®

Self-Injectable Drug Benefits



Durable MedicalEquipment ratherthan PrescriptionDrug BenefitHMO 2200: 75%HMO 2600: 70%

Blood test strips- Durable Medical Equipment

Urine test strips - Prescription Drug Benefits




Must be prescribed byPlan physician, inaccord with our drugformulary guidelines

Must use plan pharmacies (including affiliated pharmacies)



Covered as Medical Supplies, ratherthan Prescription Drug BenefitPPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% PPO 4500:In-Network: 60% Out-of-Network: 50%


Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% PPO 4500:In-Network: 60% Out-of-Network: 50%

Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% PPO 4500:In-Network: 60% Out-of-Network: 50%

Medical Benefit

Yes—required through Pharmacy

May use mail order vendor or contracted pharmacy vendor

Health NetPPO

Western HealthAdvantage HMO



Durable MedicalEquipment ratherthan PrescriptionDrug BenefitHMO 1800: 100%HMO 2800B: 80%


Durable MedicalEquipment Benefit:HMO 1800: 100%HMO 2800B: 80%

Durable MedicalEquipment Benefit:HMO 1800: 100%HMO 2800B: 80%

Medical Benefit

Yes

Depends on Medical Group

29

HSA California

† Vendors for Diabetes Equipment: Pending Benefits are typically covered

under the pharmacy benefit withparticipating pharmacies. Health Net will only cover certain machines

Contract is with Medical Group. See PCP




Refer to summary on page 28


Refer to summary on page 28

Prescriptions

FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?Refer to summary on page 28

Are non-formulary drugs available?Refer to summary on page 28

MAIL ORDER - 90 DAY SUPPLYRefer to summary on page 28

HSA California

30

KEY TO HEALTH CARE SERVICE PLANSOFFERING LISTED PROGRAM:

HN Health NetKP Kaiser PermanenteWH Western Health Advantage

* All HSA California ® medical members are eligible for discounts on eye exams, lenses, frames, and contacts through the Vision OneEye Care Program administered by Cole Managed Vision/EyeMed Vision Care.


2 Discounts on vitamins and herbal supplements available through the “Affinity Program” which links Kaiser Permanente members toHealthy Roads.


Which health care plans offer these discounts, awards and other value-added benefits?

Eyewear & lenses discount..............................................................................................................................................KP 1

Health club membership or fitness equipment/sporting goods discount ........................................................HN, KP, WH

Health literature, telephone tapes and/or videos (no charge) ..................................................................................HN, KP

available in the following languages: Spanish

Home childproofing products discount ..........................................................................................................................HN

Infant car seat:

discount ............................................................................................................................................................HN

awarded upon prenatal class completion ..........................................................................................................HN

Nurses 24 hour hotline ..............................................................................................................................................HN, KP

Vitamins and/or herbal supplements discount ........................................................................................................HN, KP 2

Weight control program discount............................................................................................................................HN, KP 3

Discounts, Awards & Other Value-Added Benefits HSA California


Colusa

Calaveras Marin

Monterey

Sacra- mento

Alameda

Alpine Amador

Butte

Contra Costa

Del Norte

El Dorado

Fresno

Glenn

Humboldt

Imperial

Inyo

Kern

Kings

Lake

Lassen

Los Angeles

Madera

Mariposa

Mendocino

Merced

Modoc

Mono

Napa

Nevada

Orange

Placer

Plumas

Riverside

San Benito

San Bernardino

San Diego

San Francisco

San Joaquin

San Luis

Obispo

San Mateo

Santa Barbara

Santa Clara

Santa Cruz

Shasta

Sierra

Siskiyou

Solano

Sonoma

Stanislaus

Sut- ter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo

Yuba

yTrininity Tr

Plan may not be available in all ZIP Codes withincounty. Check with your Kaiser Permanente ChoiceSolution representative to confirm if coverage isavailable for your group location.�All Plan Types Available

HMO, POS & PPO

PPO Only

31



32

Kaiser Permanente Choice Solution

www.choiceadmin.com

Carrier Contact Information

Member Support Kaiser Permanente Choice SolutionCustomer Service Center

English 800-580-9626

Kaiser PermanenteEnglish 800-464-4000Spanish 800-788-0616


Internet Support www.kpchoicesolution.com


Renewal Changes Employer Fax 800-566-7803 Employee Fax 800-566-8514

Commissions/Broker Services 800-542-4218, Ext. 4390

Adds/Terms Fax 800-566-8514

Missing BOR Changes Fax 800-580-9626

Claims Kaiser Permanente Claims 800-464-4000

To contact by mail or for payment submissions CHOICE Administrators ®

721 South Parker Suite 200 Orange, CA 92868


MEDICAL


LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

Products Offered

OptionalBenefits

GROUP SIZE


HMO PPO POS


HSA-CompatibleDHMO

HRA-CompatiblePPO

MRP-CompatiblePPO

Available

Available

Not Available

HMO: Benefits vary by planPOS/PPO: Benefits vary by plan

Not Available

Not Available

Not Available

HMO 10HMO 30

HMO 20/$1,000HMO 40/$2,8 00

N/A

30/$500 20/$1,000

HDHP 1900*HDHP 2700*

N/A



2-50

Is Workers' Comp required on corporate officers, partners and sole proprietors?

Is on-the-job covered for corporate officers, partners and sole proprietors? Yes

Is there a premium adjustment for24 hour coverage? No


How often can members change their Primary Care Physician (PCP)?

Can family members each choose a PCP from a differentIPA/Medical Group?Yes—HMO: From Kaiser Permanentephysicians

POS/PPO: From PHCS Network

HMO/EPO

Kaiser Permanente

POS/PPOPrivate Healthcare Systems (PHCS)

Anytime—change is effective immediately

No

24 HOUR COVERAGE


No prior authorization or referralfor OB/GYN (can be primaryprovider)Other specialists: Yes—to certainspecialties. Self-refer specialtieslist varies by geographical region

Yes—referral direct from physician

Express referral available?

SELECTION

NETWORKS


33





EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?No

Management/Non-management?No

Union/Non-union?Yes—coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have union coverage

Minimum group size

2

Does carrier underwrite and ratecarve out groups according to AB1672 guidelines?Yes


Employees

For Dependents

% of Total Cost:


Carve Outs*

Wrap* Requirements




Are commission-only employees allowed? Yes—if on quarterly/annual wage report and showing at least minimum wages and withholdings



Is coverage available for out-of-state employees?

Yes

Max. percentage of employees residing out-of-stateallowed 49% (At least 51% of eligible employees must live or work in California)

2-50


N/A

N/A

2 2

50* N/A 2-50 Yes—contact your Kaiser Permanente Choice Solution representative regarding guidelines

2-50 Yes—contact your Kaiser Permanente Choice Solution representative regarding guidelines


2 2

50* N/A

AFTER INITIAL ISSUE

100% of employees not coveredby group insurance and 70% of allemployees regardless of othercoverage



34


GROUP SIZE


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE


†

*100% ◆70%

N/A N/A

Employees

Dependents

2-2 3-50

*100%

N/A N/A

Employees

Dependents


Current Employees

TimelyAdd-ons

Group Size


Apply Trend Factor?

Use Employee ZIPs?











FEES



Monthly Billing Fee



GROUP SIZE

Rating Information

†† According to the California Insurance Code “The standardemployee risk rates applied to a small employer for new business shall be in effect for no less than six months.”


Medical Conditions

Years in Business

# of Pregnancies

Virgin Group

Type of Industry

Percent of Owners

Group Size

% of COBRA Insureds

% of Family Related

Participation

Plan(s) Requested



Bankruptcy

Gender Mix



1st of the month

Balance Due

Min: 1st of the month following date of hire Max: 180 days

60 days


Yes

No

Yes


None

N/A

2-8 9-20 21+$20 $25 $30

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No


2-5: 1.106-15: 1.00

16-50: 0.90

12 Months

No

Yes


HMO: N/APPO: Yes**

No**This does NOT include credit for the RX deductible


35








Yes

Call representative

Yes*

Yes*

Yes

Kaiser PermanenteChoice Solution


Call 800-511-0001www.choiceadmin.com

Prescriptions

GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive a genericequivalent rather than a brand name drug?HMO/POS/PPO: Yes

If doctor writes “dispense as written” on prescription, is brand name available at the brandcopay amount?HMO/POS/PPO: Yes

FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?Yes

Are non-formulary drugs available?Yes

MAIL ORDER - 100 DAY SUPPLYHMO $10 - 1 copay for up to 100 day supply (mail order or pharmacy)

HMO $30 - 1 copay for up to 100 day supply, Brandhas $100 deductible (mail order or pharmacy)

Are oral contraceptives covered?Yes

BENEFIT INFORMATION SHOWN ON THIS PAGE IS A BRIEF SUMMARY. LIMITATIONS AND EXCLUSIONS APPLY. PLEASE REFER TO CERTIFICATE BOOK, EVIDENCE OF COVERAGE OR CALL REPRESENTATIVE FOR DETAILS.


AetnaDiabetic & Self-Injectable Drug Benefits

Are the following items covered under the Prescription Drug Benefit or the Durable Medical Equipment Benefit of the member’s selected plan design?

DIABETES BENEFITS

InsulinNeedles &Syringes


Insulin PumpSupplies Insulin Pump† Glucose Monitor†

Rx Drug Benefit ■ ■ ■ Urine test strips


■ Blood test strips ■ ■ ■

†Vendors for Diabetes Equipment: Pending

These services may change at any time without notice. Please contact your Kaiser Permanente Choice Solution rep for specific inquiries on listed services


36


SELF-INJECTABLE DRUGBENEFITS

Are self-injectable drugs(other than insulin)covered under the

Prescription Drug Benefitor Medical Benefit?


*Must self-injectables(other than insulin)

be purchased via thecarrier-contracted

mail order Rx vendor?

HMO Prescription Drug Benefit No Use plan pharmacies

(including affiliated)

POS Prescription Drug Benefit No Use plan pharmacies


PPO Prescription Drug Benefit No Use plan pharmacies


37

CaliforniaChoice®† CaliforniaChoice 51+ HSA California®

Kaiser PermanenteChoice Solution

Are Hearing Aids Covered?

No No No No

HearingTreatment

HMO:Routine hearing screening inPCP's office only—office visit

copay applies.

PPO:Covers ear screenings todetermine the need for

audiograms for dependentchildren through age 18 only.

HMO:Routine hearing screening inPCP's office only—office visit

copay applies.



HMO:Routine hearing screening in

PCP's office—office visit copay applies.



HMO:Medical exams of the ear and audiometric exam to

measure hearing.

POS/PPO:Call your

Kaiser Permanente ChoiceSolution representative.

Infertility HMO & POS:$1500 lifetime maximum on

infertility drugs. Evaluation andtreatment using coveredprocedures (no in-vitro

fertilization)—50% of allowedcharges. Note: Covered

procedures and allowed chargeswill vary by HCSP (Health Care

Service Plan).

See Evidence of Coverage orBenefit Booklet.

PPO:See Evidence of Coverage or

Benefit Booklet.

HMO & POS:$1500 lifetime maximum on

infertility drugs. Evaluation andtreatment using coveredprocedures (no in-vitro

fertilization)—50% of allowedcharges. Note: Covered

procedures and allowed chargeswill vary by HCSP (Health Care

Service Plan).

See Evidence of Coverage orBenefit Booklet.

PPO:See Evidence of Coverage or

Benefit Booklet.

Not Covered HMO:50% for diagnosis and treatment

of cause of infertility.

POS/PPO:Benefits vary by plan.

Speech Therapy

HMO & POS:Outpatient covered if HCSP

determines there will besignificant improvement in 60

days—office visit copay applies.

PPO:Covered for certain conditions

(see Evidence of Coverage or callrepresentative)—subject to

deductible and coinsurance.

HMO & POS:Outpatient covered if HCSP

determines there will besignificant improvement in 60


PPO:Covered for certain conditions

(see Evidence of Coverage or callrepresentative)—subject to


HMO:Outpatient covered

if HCSP determines there will besignificant improvement in 60


PPO:Covered for certain conditions(see Evidence of Coverage orcontact your Word & Brownrepresentative)—subject to


HMO:Covered if medically necessary.

PPO:Covered if medically necessary.

POS:Covered if medically necessary.

Additional Health Plan Comparison Information


NOTE: Unless otherwise noted, information shown on this page reflects in-network benefits. For Triple Option plans, the most managed plans are shown.

† Salud HMO y Más plan design varies depending on whether the Salud provider network or the SIMNSA provider network is utilized by the employee and dependents. The information outlined onthis page only reflects the Salud provider network. Call your Word & Brown representative for Mexico benefit details.

38

Ancillary ConsumerExchange Program

39

40

PPO Silver*PPO Gold*PPO Platinum*

Ameritas GroupPPO

Out-of-State Coverage

California Coverage Area

Dual Option (Mix and Match)

3 Dental Carriers / 3 Vision Carriers / Chiro-Acupuncture / Life. Call your Choice Builder representative for more details.


Products Offered

Is coverage offered for out-of-state employees?

What is the minimum percentage of employees requiredin CA?

What dental benefits (or plan types, such as PPO,indemnity, etc.) are offered for out-of-state employees?

What states are allowed (or not allowed) for out-of-state coverage?

Are dental rates for out-of-state employees based on the CA employer ZIP Code or based on out-of-state ZIPCode?

Any other rules, restrictions, or guidelines not mentioned:

HMO Silver*HMO Gold*

Ameritas Group – PPO network Delta Dental HMO – DeltaCare USADelta Dental PPO – Delta Dental PPONetworkEyeMed (provided by Ameritas Group)Access NetworkMadison National Life – Dental (Providedby GroupLink Inc.) – FDH NetworkMadison National Life – Vision (Providedby Davis Vision)Landmark Healthplan – ChiropracticVSP - Vision – VSP Choice Network

Coverage area varies by plan. Please contactyour Choice Builder® representative for a quote

Delta Dental

Yes

N/A

All states eligible

EPO, PPO and indemnity

Delta Dental DHMO is rated by employee ZIP Code, all other carriers are rated by employer ZIP Code

Employer’s home office must be located in CA. If incorporated inanother state, documents must show a home office address in CA.

Benefits are offered both as Employer Sponsored and Voluntary (except Life).Employer must purchase dental in order to offer any other line of coverage. Group must offer 1 PPO/Indemnity/EPO dental carrier to go along withthe Delta Dental DHMO carrier. Group Size: 2-99

HMO

EPO Silver*

Madison NationalLife Insurance Company

EPO Indemnity

Indemnity Platinum*

Madison National Life Insurance Company

Dental

EyeMedSilver*Gold*Platinum*

VisionVSPSilverGold*Platinum*

Madison National LifeInsurance CompanySilver*Gold*Platinum*

*Available both Employer Sponsored and Voluntary.

Landmark Healthplan*Call your Choice Builder representative for more details

Chiropractic/AcupunctureAssurity LifeCall your Choice Builder representative for more details

Life

41

PPO Gold (Employer sponsored only)PPO Silver (Voluntary only)

Delta Dental

PPO Gold*

Madison NationalLife Insurance Company

www.choiceadmin.com

Customer Service CenterChoice Builder 866-412-9279Member Service DentalAmeritas Group 800-487-5553Delta Dental HMO 800-422-4234Delta Dental PPO 888-335-8227Madison National Life 866-412-9279VisionMadison National Life (Davis Vision) 800-999-5431 EyeMed (provided by Ameritas) 866-289-0614VSP 800-877-7195Chiropractic/AcupunctureLandmark Healthplan 800-638-4557LifeAssurity Life Insurance Company 800-869-0355Commissions Choice Builder 714-567-4390Add-ons/Deletes Choice Builder Fax 866-412-9280

Dental Claims Delta Dental12898 Towne Center DriveCerritos, CA 90703

Ameritas GroupP.O. Box 82520Lincoln, NE 68501Fax 402-467-7336

Madison National lifeCX015 Grouplink Inc.P.O. Box 20593 Indianapolis, IN 46220877-223-4693

ANCILLARY CONSUMER EXCHANGE PROGRAM


Employer Sponsored

• Minimum Employee participation must be at least 70%• Minimum Dependent participation is 0%

Dental Benefits

Participation Requirements

Voluntary

• Minimum of 10 eligible Employees with a minimum participation of at least 5 enrolled in dental

• Minimum Dependent participation is 0%


• The Employer must contribute at least 50% of the lowest cost benefit design

• No Employer contribution is required for Dependent coverage

Minimum Employer Contribution

• No Employer contribution requiredMinimum Employer Contribution

Employer Sponsored

• Minimum Employee participation must be at least 70%• Minimum Dependent participation is 0%

Vision Benefits


Voluntary

• No minimum participation requiredParticipation Requirements

• The Employer must contribute at least 50% of the lowest cost benefit design

• No Employer contribution is required for Dependent coverage



Employer Sponsored

• 100% Employee participation is required• Minimum Dependent participation is 0%

Chiropractic/Acupuncture Benefits


Voluntary

• No minimum participation requiredParticipation Requirements

• The Employer must contribute 100% of the Employee premium

• Dependent Coverage is included as this is a discount plan only



Employer Sponsored

• 100% Employee participation is required

Life Benefits


• The Employer must contribute 100% of the Employee premiumMinimum Employer Contribution

42

www.choiceadmin.com ANCILLARY CONSUMER EXCHANGE PROGRAM

Are commission-only employees allowed? No


Any ineligible industries? Yes—Delta Dental PPO Employer sponsored plan—contact your Choice Builder® representative; and Dental offices for Madison National Life

Virgin groups eligible? Yes

Quarterly/annual wage report required?Upon request

Rating Information



Union/Non-union?Yes—eligible non-union members only. Employer tosubmit union billing

Minimum group size2

Carve Outs*

Orthodontic Coverage

Waiting Period Waiver/Takeover

Out-of-Network Claim Adjudication


Group Size

Rate Guarantee

Rates Vary by Industry?

Coverage Requirements

2-99

12 months

Delta Dental DHMO – (included) no wait

Delta Dental DPPO ††† – Employer sponsored: no waitVoluntary: 12 months

Ameritas Group†† – 12 month wait†

Madison National Life†† – Employer Sponsored: 12 months;Voluntary: 12 month wait

† Ameritas Dental optional ortho benefit only available togroups of 5 or more employees.

†† Waiting Periods can be waived if there is a minimum of 10employees enrolled on a Choice Builder PPO dental plan andthe employer has a current comparable PPO dental planinforce. Partial and/or Full Credit given for entire initialenrolling population. Billing from 12 months ago and currentbill is required at underwriting, and possibly the currentcarrier’s Benefit Booklet.

††† Delta Dental employer sponsored plan optional ortho benefitonly available to groups of 10 or more employees, voluntaryplan optional ortho benefit only available to groups of 25 ormore employees.

All newly enrolled employees after initial enrollment aresubject to wait periods below (Basic / Major / Ortho):

Ameritas Group – Employer Sponsored or Voluntary:3/12/24 months

Madison National Life – Employer Sponsored or Voluntary:3/12/12 months

HMO: N/AMadison National LifeIndemnity – 90th percentile; EPO/PPO – Max. allowablecharge.

Ameritas GroupSilver Benefits – Average prevailing fee; Gold/Platinum Benefits – 80th percentile of U&C

Delta Dental PPOMax. allowable charge.

Delta Dental DHMO – N/A

Delta Dental PPO – N/A

Madison National Life – At initial group enrollment, groups with 10+ eligibleemployees and prior continuous orthodontic dentalcoverage, will waive up to 12 months waiting period basedon group’s number of prior continuous uninterruptedorthodontic coverage.

Ameritas Group – At initial group enrollment, employer-sponsored groupswith 10+ eligible employees and prior continuousuninterrupted orthodontic coverage of 12 months will waiveorthodontic waiting period.

Dental- varies by carrierLife - YesVision & Chiro - No

43

www.choiceadmin.comANCILLARY CONSUMER EXCHANGE PROGRAM

44

Dental

45

46



Products Offered



What plans (or plan types, such as PPO, indemnity, etc.)are offered for out-of-state employees?


Are rates for out-of-state employees based on the CAemployer ZIP Code or based on out-of-state ZIP Code?


CaliforniaChoice has optional dental that can be offered along with medical.Employers may elect to offer one of the following to their employees:

■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3000 & 3500, and PPO 4000& 5000 WITHOUT Ortho

■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3000 & 3500*, and PPO4000* & 5000* WITH Ortho

■ Voluntary Prepaid 3000 and FDH Access 100**■ FDH Access 100 only**

Employees may select the best dental plan to fit their needs out of those plansoffered by their employer.

* PPO plans with Ortho are only available to groups with 5 or more eligible employees.

** FDH Access 100 is included in the program at no additional cost and offers services atreduced fees. Employees and dependents (if applicable) must be enrolled for medicalcoverage through the CaliforniaChoice Program.

FDH 100: All CountiesSmileSaver Plan 1000 & 3000: All Counties

Plan 3000 & 3500: All Counties


Plan 3000Plan 3500

2-502-50

Plan 4000Plan 5000

2-502-50

Yes

California HMO Counties:

California EPO Counties:

California PPO Counties:

† If employer currently is not offering dental, FDH (First Dental Health) Access 100 Dental Program (if elected) is included at noadditional cost for employees and their dependents enrolled in CaliforniaChoice medical.

* Prepaid 3000 also is available on a voluntary basis with no minimum employee participation requirement.

FDH Access 100†

Plan 3000* Plan 1000

2-502-502-50

Prepaid/HMO Group Size

EPO Group Size

PPO Group Size


CaliforniaChoice dental is available only to groups with CaliforniaChoice medical coverage

FDH Access 100:First Dental Health Access

Plan 1000 & 3000:SmileSaver Dental

PROVIDER INFORMATION

Indemnity Network


Plan 3000 & 3500:First Dental Health EPO

Plan 4000 & 5000:Ameritas PPO

51%

All are allowed except Hawaii

PPO and EPO

It is based on the employer ZIP Code

N/A

47

www.choiceadmin.com

Customer Service CenterCaliforniaChoice® 800-558-8003Member ServiceAmeritas Group 877-203-0036FDH Access 800-558-8003 SmileSaver 800-880-1800CommissionsCaliforniaChoice 714-542-6992 x4390Dental ClaimsAmeritas Group (EPO/PPO): Ameritas Group

P.O. Box 82520 Lincoln NE 68501 877-203-0036 Fax 402-467-7336

SmileSaver SmileSaver Attn: Claims Dept. P.O. Box 30920 Laguna Hills, CA 92654 800-880-1800Add-ons/DeletesCaliforniaChoice Fax 714-558-8000

HMO Network

EPO Network

PPO Network

DENTAL

HMO N/A

EPO & PPO For groups with 10 or more employees, the12 month waiting period for major serviceswill be waived for individuals who wereenrolled under this employer’s comparablegroup dental plan for 12 months or more.Groups without prior comparable dentalcoverage are subject to the waiting period.Credit will be given for time on the priorplan. If orthodontia was covered oncomparable prior plan, credit will be giventoward the 24 month ortho waiting period.


FDH Access 100—$4,277 copay for child or adult ortho Plan 1000 & 3000—$1600 copay for child/$1950 copay foradult

Employees

Dependents

Employees

Dependents

Employees

For Dependents

% of Total Cost:

Rating Information

MINIMUMEMPLOYERCONTRIBUTION

PARTICIPATION

GROUP SIZE

GROUP SIZE

◆ Those covered by another plan are NOT considered eligible in calculating participation◆◆ In order to NOT be considered eligible, the other coverage must be a group plan



Union/Non-union?

Minimum group size

Carve Outs*

HMO


Out-Of-Network Claim Adjudication


Group Size

Rate Guarantee


COVERAGE REQUIREMENTS



Union/Non-union?

Minimum group size

Are commission-only employees allowed? Yes—if on quarterly/annual wage report and showing atleast minimum wages and withholdings

Are 1099 employees allowed?No

Any ineligible industries?No

Virgin groups eligible?Yes

Quarterly/annual wage report required?Yes

No

No

Yes – coverage available for non-union only. Group must submit union billing to underwriting forverification that all other employees have medical coverage.

2

2-50

2-50

2-50

12 Months

No

2-50 Plan 3000Voluntary

0%

0%

0%


0%

0%

◆◆ 100%

0%

0%

0%

EPO & PPO

0%

0%

50% of employee only premiumfor lowest cost plan offered

◆◆ 70%

0%

Coverage RequirementsWaiting Period Waiver/Takeover

Special ConsiderationsEnrollment for spouse and children is contingent on employeeenrollment. Dependent enrollees for dental cannot differ fromdependent enrollees for medical coverage (except for childrenunder age 3). However, if dependents do not enroll in medical,then any dependent make-up for dental is acceptable.

HMO N/A

EPO Plan 3000 & 3500 - Out of network claims are paid basedupon the maximum allowable charge or scheduled charge. Forgroups of 2-4 employees, out-of-network restorative is coveredat 50% with no waiting period.

PPO Plan 4000 & 5000 - Out of network claims are paid basedon U & C 80th percentile. For groups of 2-4 employees, out-of-network restorative is covered at 50% with no waiting period.

48

www.choiceadmin.com

Plan 3500, 4000 & 5000—Optional benefit* available togroups of 5 or more eligible employees. 50% to No AnnualMaximum/$1000 Lifetime Maximum. 24-month wait exceptfor 10+ groups that meet the criteria outlined in waitingperiod waiver section below.

* Orthodontia is an optional benefit chosen for theentire group by the employer.

DENTAL

Contributory

Non-Contributory

49



Products Offered


What is the minimum percentage of employees required inCA?

What plans (or plan types, such as PPO, Indemnity, etc)are offered for out-of-state employees?




CaliforniaChoice 51+ has optional dental that can be offered along with medical.Employers may elect to offer one of the following to their employees:

■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3000 & 3500, and PPO 4000 &5000 WITHOUT Ortho

■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3000 & 3500, and PPO 4000 &5000 WITH Ortho

■ Voluntary Prepaid 3000 and FDH Access 100**■ FDH Access 100 only**

Employees may select the best dental plan to fit their needs out of those plans offeredby their employer.

** FDH Access 100 is included in the program at no additional cost and offers services atreduced fees. Employees and dependents (if applicable) must be enrolled for medicalcoverage through the CaliforniaChoice 51+ Program.

HMO Network

FDH 100: All CountiesSmileSaver Plan 1000 & 3000: All Counties



Plan 3000Plan 3500

51-19951-199

Plan 4000Plan 5000

51-19951-199

Yes




† If employer currently is not offering dental, FDH (First Dental Health) Access 100 Dental Program (if elected) is included at noadditional cost for employees and their dependents enrolled in CaliforniaChoice 51+ medical.

* Prepaid 3000 also is available on a voluntary basis with no minimum employee participation requirement.

Customer Service CenterCaliforniaChoice 51+ 866-451-7587Member ServiceAmeritas Group 877-203-0036FDH Access 800-558-8003 SmileSaver 800-880-1800CommissionsCaliforniaChoice 51+ 714-542-6992 x4390Dental ClaimsAmeritas Group (EPO/PPO): Ameritas Group

P.O. Box 82520 Lincoln NE 68501 877-203-0036 Fax 402-467-7336

SmileSaver SmileSaver Attn: Claims Dept. P.O. Box 30920 Laguna Hills, CA 92654 800-880-1800Add-ons/DeletesCaliforniaChoice 51+ Fax 714-664-1711

FDH Access 100+ Plan 3000* Plan 1000

51-19951-19951-199


EPO Group Size

PPO Group Size

Dual Option (Mix And Match)

CaliforniaChoice 51+ dental is available only to groups with CaliforniaChoice 51+ medical coverage

FDH Access 100:First Dental Health Access



Indemnity Network

EPO Network

PPO Network

Plan 3000 & 3500First Dental Health EPO


51%


PPO and EPO


N/A

www.choiceadmin.comDENTAL

50

HMO N/A

EPO & PPO For groups with 10 or more employees, the12 month waiting period for major serviceswill be waived for individuals who wereenrolled under this employer’s comparablegroup dental plan for 12 months or more.Groups without prior comparable dentalcoverage are subject to the waiting period.Credit will be given for time on the priorplan. If orthodontia was covered oncomparable prior plan, credit will be giventoward the 24 month ortho waiting period.


FDH Access 100—$4277 copay for child or adult ortho Plan 1000 & 3000—$1600 copay for child/$1950 copay foradult

Plan 3500, 4000 & 5000—Optional benefit* available togroups of 5 or more eligible employees. 50% to No AnnualMaximum/$1000 Lifetime Maximum. 24-month wait exceptfor 10+ groups that meet the criteria outlined in waiting period waiver section below.

* Orthodontia is an optional benefit chosen for theentire group by the employer.

Employees

Dependents

Employees

Dependents

Employees

For Dependents

% of Total Cost:

Rating Information


PARTICIPATION

GROUP SIZE

GROUP SIZE




Union/Non-union?

Minimum group size

Carve Outs*

HMO




Group Size

Rate Guarantee


COVERAGE REQUIREMENTS



Union/Non-union?

Minimum group size

Are commission-only employees allowed? Yes—if on quarterly/annual wage report and showing atleast minimum wages and withholdings





No

No

Yes – coverage available for non-union only. Group must submit union billing to underwriting forverification that all other employees have medical coverage.

51-199

51-199

51-199

51-199

12 Months

No


0%

0%

0%


0%

0%

◆◆ 100%

0%

0%

0%

EPO & PPO

0%

0%


◆◆ 70%

0%

Coverage RequirementsWaiting Period Waiver/Takeover


HMO N/A

EPO Plan 3000 & 3500 - Out of network claims are paid basedupon the maximum allowable charge or scheduled charge. Forgroups of 2-4 employees, out-of-network restorative is covered at50% with no waiting period.


Contributory

Non-Contributory

www.choiceadmin.com DENTAL

51



Dual Option (Mix and Match) Provider Information

Products Offered







SmileSaver Plan 1000 & 3000: All Counties



Yes




51%


PPO and EPO


N/A

HSA California has optional dental that can be offered along with medical.Employers may elect to offer one of the following to their employees:

■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3000 & 3500, and PPO 4000& 5000 WITHOUT Ortho

■ All buy-up dental plans: Prepaid 1000 & 3000, EPO 3000 & 3500*, and PPO4000* & 5000* WITH Ortho*

■ Voluntary Prepaid 3000

Employees may select the best dental plan to fit their needs out of those plansoffered by their employer.

* PPO plans with Ortho are only available to groups with 5 or more eligible employees.

Plan 3000Plan 3500

2-502-50

Plan 4000Plan 5000

2-502-50

* Plan 3000 is also available on a voluntary basis with no minimum employee participation requirement.

Plan 3000* Plan 1000

2-502-50


EPO Group Size

PPO Group Size

HSA California dental is available only to groups with HSA California medical coverage


Plan 3000 & 3500: First Dental Health Network


www.choiceadmin.com

Customer ServiceHSA California® 866-251-4718Member ServiceAmeritas Group 877-203-0036SmileSaver 800-880-1800CommissionsHSA California 714-542-6992 x4390Dental ClaimsAmeritas Group (EPO/PPO): Ameritas Group

P.O. Box 82520 Lincoln, NE 68501 877-203-0036 Fax 402-467-7336

SmileSaver SmileSaver Attn: Claims Dept. P.O. Box 30920 Laguna Hills, CA 92654 800-880-1800Fax (Add-ons/Deletes)HSA California 866-251-4724

EPO Network

HMO Network

PPO Network

DENTAL

Employees

Dependents

Employees

Dependents

Employees

For Dependents

% of Total Cost:

Rating Information

PARTICIPATION

GROUP SIZE

GROUP SIZE


Carve Outs*



Group Size

Rate Guarantee




2-50

2-50

2-50

12 Months

No


0%

0%

0%


0%

0%

◆◆ 100%

0%

0%

0%

0%

0%


◆◆ 70%

0%



Union/Non-union?Yes – coverage available for non-union only. Group must submit union billing to underwriting for verification that all other employees have medical coverage.

Minimum group size2

Are commission-only employees allowed? Yes, if on quarterly/annual wage report and showing at least minimum wages and withholdings






HMO N/A

EPO & PPO For groups with 10 or more employees, the12 month waiting period for major serviceswill be waived for individuals who wereenrolled under this employer’s comparablegroup dental plan for 12 months or more.All new hires and groups without priorcomparable dental coverage are subject tothe waiting period. Credit will be given fortime on the prior plan. If orthodontia wascovered on comparable prior plan, creditwill be given toward the 24 month orthowaiting period.


Plan 1000 & 3000—$1600 copay for child/$1950 copay for adult

Plan 3500, 4000 & 5000—Optional benefit* available togroups of 5 or more eligible employees. 50% to No AnnualMaximum/$1000 Lifetime Maximum. 24-month wait exceptfor 10+ groups that meet the criteria outlined in waitingperiod waiver section below.

* Orthodontia is an optional benefit chosen for theentire group by the employer..

HMO

EPO & PPO



52

www.choiceadmin.com

HMO N/A

EPO Plan 3000 & 3500 - Out of network claims are paid basedupon the maximum allowable charge or scheduled charge. Forgroups of 2-4 employees, out-of-network restorative is covered at50% with no waiting period.


DENTAL

Contributory

Non-Contributory

53




California DHMO Counties:

Boxes containing asterisks indicate that these coordinate plans offered by this carrier can be writtentogether to create a dual option package. The number indicates the minimum enrollment requiredon each of the coordinate plans. Blank boxes indicate which plans cannot be written together


Products Offered


California Indemnity Counties:







DHMO—DeltaCare® USA eligible ZIP Codes

PPO—Delta Preferred Counties

FFS—Delta Premier (all counties)

DeltaCare® USA

Delta PPOPPO

*

FFS

2-50 PPO

Prepaid/DHMO Group Size

PPO Group Size

Indemnity Group Size

2-50 FFS

* PPO—only available if employee resides in PPO plan service area FFS—only available to employees outside PPO plan service area DHMO—only available to employees residing in DHMO service area

Delta Premier

Yes

51%

All states eligible

Fee for Service Only

Employee ZIP Codes

Employer may only elect dental at initial or open enrollment. Employer cannot elect dental as a standalone product.

DHMO *

PPO

*

2-50 DHMO

www.choiceadmin.com

Customer Service CenterKaiser Permanente Choice Solution800-580-9626

Fax (Add-ons/Deletes)800-566-8514

Commissions800-542-4218, Ext. 4390

ClaimsContact carriers directly

PPO Network

Indemnity Network

DHMO Network

DENTAL

Employees

Dependents

Employees

Dependents

Are commission-only employees allowed? Yes—if on quarterly/annual wage report and showing at least minimum wages and withholdings


Any ineligible industries? No

Virgin groups eligible? Yes

Quarterly/annual wage report required?No—payroll OK

Employees

For Dependents

% of Total Cost:

Rating Information


PARTICIPATION

GROUP SIZE

GROUP SIZE




Union/Non-union?

Minimum group size

Carve Outs*

Special Considerations

DHMO






Group Size

Rate Guarantee


PPO

FFS


No waiting period

Yes

No

No

Non-union only

2

All plans

2-50

2-50

12 Months

No

◆◆ 100%

0%

50%

0%50% of employee only premium

for lowest cost plan offered

◆◆ 70%

0%Yes—$1,500 lifetime maximum

Yes—$1,500 lifetime maximum

DHMO—only available if employee resides in DHMOplan service area

PPO—only available if employee resides in PPO planservice area

FFS—only available to employees outside PPO planservice area

54

www.choiceadmin.com

PPO Delta-approved fee schedule

FFS Plan allowance based on fees that satisfy the majority of Delta dentists or submitted fees (whichever is less)

DENTAL

Contributory

Non-Contributory

www.choiceadmin.com721 South Parker, Suite 200Orange, CA 92868

800.511.0001

CA17953.1.13

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