BLUE SHIELD HMO PLAN EFFECTIVE 4/1/02
Annual Deductible	$1,500 (single) / $3,000 (family) that applies to facility charges for inpatient hospital services,
	outpatient hospital surgery services, skilled nursing facility services, & ambulatory surgery
	center services.
Your Maxiumum Out of Pocket Costs	$3,000 single / $6,000 family
Your Choice of Physicians	You must choose a Physician from the
	Directory as your Personal Physician
Lifetime Benefit	Unlimited
Pre-existing Condition/s Waiting Period	None
Office Visits-your portion	$10 CoPay
Hospitalization - using a Choice Provider	Pays 100% after $1,500 Deductible
Hospitalization - using a Affiliated Provider	Additional $150 CoPay per admission; Pays 100% after $1,500 Deductible
Maternity - using a Choice Provider	Pays 100% after $1,500 Deductible
Maternity - using an Affiliated Provider	Additional $150 CoPay; Pays 100% after $1,500 Deductible
Outpatient surgery/supplies	$150 per visit with a Choice Provider / $250 per visit with an Affiliated Provider
Laboratory & X-ray	No Charge
Hospital outpatient treatment/procedure	$25 CoPay - Choice / $35 CoPay - Affiliated
Ambulance	$50 CoPay
Emergency Room Services	$50 CoPay (If admitted CoPay is waived & $1,500 Ded. applies)
Mental Health Services (inpatient & outpatient) are covered as any other illness for SEVERE conditions.
Mental Health - Non Severe Outpatient visits	$10 CoPay (limited to 20 visits per year)
Acupuncture	Not Covered
Chiropractic Care	Not Covered
PREVENTIVE CARE
Annual Routine Physical Exams	$10 CoPay
Well-baby Care office visits	$10 CoPay
Annual Pap Tests & Mammography	$10 CoPay
OUT PATIENT PRESCRIPTIONS
Generic (30 day supply)	$10 CoPay
Brand name (30 day supply)	$30 CoPay
Mail Order Prescription (60 day supply)	$20 CoPay - generic / $60 CoPay - brand name
Blue Shield policies include an alternative health and wellness program called 'mylifepath' which offers discounts on certain services. They also have
a very resourceful website which gives more information about their plans and services, the website address is www.mylifepath.com
NOTE: This is a Summary of Benefits and assumes Member uses PARTICIPATING PROVIDERS. Benefits are not covered
if NON-PARTICIPATING PROVIDERS are used, except for Emergency Services.