HMO Medical Benefits Carrier: Blue Cross of California Policy Number: 57726 Eligibility: Active full time ALADS member in Continuous pay status Waiting Period: First day of the month following one month of active employment Your Monthly Contribution: Member $0.00   Member + 1 Dependent $0.00   Member + 2 or more Dependents $0.00     Deductible None Out-of-Pocket Maximum   Individual   Family   $500 per calendar year $1,500 per calendar year Lifetime Maximum Unlimited Doctor Office Visits $5 copay per visit Immunizations No charge X-rays and Lab Tests No charge Hospital Care No charge Surgery No charge Ambulance No charge Emergency Room $25 copay, waived if admitted as inpatient Maternity Office Visits: $5 copay; Hospital Stay: No charge Chiropractic $5 copay up to 60 days per injury (additional 20 visits through ASHP) Acupuncture Not covered Physical Therapy $5 copay, up to 60 day per condition Home Health Care $5 copay Hospice Care No charge Skilled Nursing Facility No charge up to 100 days per calendar year maximum Infertility Benefit Diagnosis & Testing 50% Tubal Ligation $150 Vasectomy $50 Family Planning $5 Durable Medical Equipment No charge, up to $2,000 per calendar year Mental Health and Substance Abuse Inpatient Outpatient   Drug and alcohol detox only $20 copay per visit, 20 visits per year maximum Pharmacy Retail (member drugstore) Mail Order   $5 generic/$10 name brand (30 day supply) $5 generic/$5 name brand (90 day supply) Vision Benefits Carrier: Vision Service Plan (VSP) Policy Number: 00115353 Eligibility: All ALADS Members and their families who are enrolled into the Premier Blue Cross Medical Plan   VSP-Provider Non-VSP Provider Exams One exam every 12 months $55 once every 12 months Lenses (1 pair every 24 months)   Single   Bifocal   Trifocal   Lenticular   Covered in full Covered in full Covered in full Covered in full   Up to $45 Up to $65 Up to $85 Up to $125 Frames (1 every 24 months) Up to $120 Up to $47 Contact Lenses (1 every 24 months)   Visually Necessary   Elective   Covered in full* Covered up to $120   Up to $250* Covered up to $105 Low Vision   Supplemental Testing   Supplemental Aids   Covered in full* 75% of cost   Up to $125* 75% of cost Maximum Allowance for Low Vision $1,000 every 2 years $1,000 every 2 years * Subject to copay Links Blue Cross of California HMO EOC Booklet HMO 2007 Amendment Dental EOC Booklet Dental 2007 Amendment VSP Benefit Summary Benefits Hotline or call 1-800-842-6635

This is a summary only, please refer to the actual policy for complete details
These benefits represent the "standard" benefits.
There may be modifications for some states due to mandated benefits that are not reflected in this benefit plan design

© 2003 Fickewirth & Associates. All rights reserved