Medical Benefits Carrier: Blue Cross of California Policy Number: 67915 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 $161.18   Member + 1 Dependent $296.66   Member + 2 or more Dependents $299.34     PPO Provider Non-PPO Provider Deductible   Individual   Family   $200 per calendar year $600 per calendar year Out-of-Pocket Maximum $450 per member $6,000 per member Lifetime Maximum $5,000,000 $5,000,000 Doctor Office Visits 90% 70% Well baby/Well child care (up to age 7) 90% 70% Preventive care $25 per visit up to $250 per year None Immunizations 90% 70% X-rays and Lab Tests 90% 70% Hospital Care 90% 65% Surgery 90% 70% Ambulance 80% 80% Emergency Room 90% 70% Maternity 90% 70% Chiropractic 90% 70% Acupuncture Not covered Physical Therapy 90% 70% Home Health Care 90% 70% Hospice Care 90% 80% Skilled Nursing Facility 90% 70% Durable Medical Equipment 90% 70% Mental Health and Substance Abuse   Inpatient   Outpatient   50% of covered expense after deductible, 30 days per year maximum up to $50 maximum per visit, 50 visits per year maximum   50% of covered expense after deductible, 30 days per year maximum 50% of covered expense up to $25 maximum per visit, 50 visits per year maximum Pharmacy   Retail   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 Dental Benefits Coverage provided by Blue Cross of California Eligibility: All ALADS Members and their families who are enrolled into the Premier Blue Cross Medical Plan   Provider Non-Provider Deductible   Individual   Family   $50 per calendar year $150 per calendar year Calendar Year Maximum $1,500 per person (combined provider and non-provider) Examinations No charge Teeth cleaning No charge, 2 times per 12 months X-rays No charge, 1 set of full mouth every 36 months Emergency Treatment Covered as regular treatment Oral Surgery 90% 85% of R&C Fillings 90% 85% of R&C Major benefits (12 month wait) Root Canals 90% 85% of R&C Periodontics 60% 50% of R&C Bridges 60%, once every 5 years 50% of R&C once every 5 years Crown, Jackets 60%, once every 5 years 50% of R&C once every 5 years Dentures 60%, once every 5 years 50% of R&C once every 5 years TMJ Not covered Not covered Orthodontic 50% of R&C up to $1,500 lifetime Links Blue Cross of California PPO EOC Booklet PPO 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