word & brown—broker's health plan reference guide for … · 2010-02-16 · the health...

C a l i f o r n i a

HEalTH Plan rEfErEnCE GUiDEfor Brokers

Group Health, Dental & Vision

Employer Services:

Employee Services:

Broker Services:

Carrier Online Services

1 All features are available to members who enroll on Aetna Navigator. There is no cost for Aetna Navigator.2 Service currently available with RelayHealth.com3 Employer must sign up with Kaiser Permanente’s Customer Account Services in order to access on-line services.4 Employers must register at employereservices.com.

Employees must register at myuhc.com®.Brokers must register at unitedeservices.com.

* Must be registered with Aflac Account Services in order to access online services† An employer can order ID cards for an employee.

View Employee Add-Ons

View EmployeeTerminations

Rates ForEEs/Dependents

Online Billing

Online Addition of Employee

Online Terminationof Employee

View Directory

Download Forms

E-Mail CustomerService

Premium Payment

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Aflacafl

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Blue Sh

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Califor

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Health

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Health

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HSA Cali

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Kaiser

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Sharp

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United

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View Claims Status

Order ID Cards

View Benefits

View Current PCP Or Doctor

Change Doctor

View Directory

Download Forms

Book DoctorAppointments

Manage GroupAccount

CommissionInformation

Group Information(e.g. Add-Ons)

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Helpful Plan Transition Tips for Your Clients ....3 Carrier Billing Cycles ........................................5Health Plan Comparison Chart ..........................6 Medicare Part D Prescription Coverage ..........12Broker of Record Change Requirements..........14HPV Vaccine Coverage Summary....................15Carrier RAF Summaries ..................................16

WORKSITE VOLUNTARY PRODUCTS ..............29Aflac ..........................................................31Allstate Workplace Division........................37

MEDICAL ........................................................41Aetna ........................................................43Blue Shield of California ............................49CaliforniaChoice® ......................................55California CPA............................................65Health Net..................................................71HealthEdge Cost Saver ..............................77HSA California® ..........................................83Kaiser Permanente ....................................91Kaiser Permanente Choice Solution ..........97Sharp Health Plan ....................................103UnitedHealthcare/PacifiCare ....................109UnitedHealthcare......................................115

CONSUMER DIRECTED PLANS......................121

DENTAL ........................................................129Dental Plan Comparison Chart..................130Aetna ......................................................135Allied National Companies ......................137BEST Life & Health Insurance ..................139Blue Shield of California ..........................141CaliforniaChoice®......................................143Delta Dental ............................................145Delta Dental/Morgan White Group............147Freedom Dental BEN-E-LECT....................149Golden West Dental ................................151 Health Net................................................153HSA California® ........................................155Kaiser Permanente Choice Solution..........157MetLife/SafeGuard....................................159Principal Financial Group ........................161Reliance Standard ....................................163SelectDent ..............................................165SmileSaver ..............................................167UnitedHealthcare/PacifiCare ....................169UnitedHealthcare......................................171

VISION..........................................................173BEST Life & Health Insurance ..................175Blue Shield of California ..........................177Camden Insurance – Affiliateof Vision Plan of America ........................179Principal Financial Group ........................181SafeGuard ................................................183SelectVision ............................................185Vision Plan of America ............................187

C O N T E N T S

TO OUR BROKERS:The information in this book was collected from carriers marketed throughWord & Brown and is accurate to the best of our knowledge at the time ofprinting. However, since this publication is intended strictly as a guide – andplan specifications may change – we recommend that you verify any datawith your Word & B rown sales representative and the carrier before basingany decisions on the information provided. Word & Brown disclaims any andall liability regarding the errors or omissions of the carriers.

INLAND EMPIREEmpire Towers

3633 Inland Empire Blvd., Suite 525Ontario, CA 91764

877-225-0988909-945-2224 • Fax 909-945-3339

LOS ANGELES801 N. Brand Blvd., Suite 900

Glendale, CA 91203 800-560-5614

818-247-2861 • Fax 800-355-9711

NORTHERN CALIFORNIA1737 N. First Street, Suite 680

San Jose, CA 95112800-255-9673

408-437-5929 • Fax 408-437-5925

ORANGE721 South Parker, Suite 300

Orange, CA 92868800-869-6989

714-835-6752 • Fax 714-953-9404

SAN DIEGO3131 Camino Del Rio North, Suite 820

San Diego, CA 92108800-397-3381

619-299-5001• Fax 619-299-2070

The Health Plan Reference Guide (HPRG) is a compilation of Carrier Plans and Services offered to youthrough Word & Brown. The HPRG provides brokers withinformation on plan commissions, benefits, enrollment andeligibility requirements and coverage areas. This information isprinted on a quarterly basis and the most up to date guidelinesare posted on our website.

www.wordandbrown.com

Helpful transition tips for your clients


Northern California 800.255.9673 ■ Los Angeles 800.560.5614 ■ Inland Empire 877.225.0988 ■ Orange 800.869.6989 ■ San Diego 800.397.3381

3

Please share these tips with all of your clients changing insurance plans

Until the new insurance plan has been approved, please make sure your clients are aware of the following:

Emergency Care –In case of an emergency situation, your client should call 911 or go to the nearest in-network hospital* for their new plan and pay cashor use a credit card for any incurred fees. Once their group is approved by the carrier, they can request reimbursement (less their plan’semergency room co-payment). Also remind clients to keep a record of their payment for submission to the carrier. Some plans waive theemergency room co-payment if the patient is admitted to the hospital directly from the emergency room. Important: The diagnosis by theemergency room physician must meet the carrier’s definition of a true emergency in order to receive any reimbursement.

* If your client is taken by car or ambulance to a non-network hospital because it’s within closer proximity than an in-network hospital, the new carrier must be notified within24-48 hours. Please have them call their company’s insurance contact person or you, the broker, if they need assistance with this notification process.

Continuity of Care/Completion of Covered Services – If your client or their enrolling spouse/domestic partner is pregnant and receiving care by a non-network doctor, your client is undergoingtreatment for an acute condition, a serious chronic condition or terminal illness by a non-network doctor or your client’s newborn child isreceiving care from a non-network doctor between birth and age 36 months, they may come under the provisions of the California lawrequiring carriers to provide continuity of care (completion of covered services) with the non-network doctor in specific circumstances. Itis important that they notify their company’s designated insurance contact person or you as soon as possible so you can assist them withsubmitting the continuity of care form to the carrier if their situation meets this law’s criteria and the carrier’s program guidelines.

Doctor Office Visit –Some offices will allow the patient to sign a waiver and pay for the visit up front. Remind your client to keep record of their payment forsubmission to the carrier along with their reimbursement form once they have their new ID number. If your client is a current patient, somedoctors will agree to bill the new insurance carrier once the patient gets their new insurance ID number and will have them pay only theoffice visit co-payment for their new plan. It is best to call the office before their appointment and explain their situation so they know whatthe payment procedures are in advance. If this visit can be postponed without adverse consequences to their health, they may want toconsider rescheduling their appointment for a later date when they have their new ID number.

Prescriptions –Clients should refill maintenance prescriptions prior to the effective date for their new coverage. For example, they should refill amaintenance high blood pressure medication no later than 12/31 for new coverage that will be effective 1/1. If they need to fill aprescription on or after the effective date for their new coverage, but they do not have their new ID number yet, they can pay for theprescription at the pharmacy and then request reimbursement from the carrier once they receive their new ID number. For reimbursement,they must submit the pharmacy receipt that includes the name of the drug & dosage rather than only the cash register receipt. If theypaid for the prescription by credit or debit card, and return to the pharmacy with their ID number within 7-10 business days, somepharmacies will credit any overpayment back to their account. This is the fastest way for them to get their money back. When amedication is expensive, some pharmacies will work with the client by allowing them to buy a smaller amount (Ex: 10-day supply). Whenthe client returns to pick up the remaining balance of their 30-day supply, the appropriate payment adjustment will be made once theyshow the pharmacy their new ID number. Some brand name drugs have generic equivalents that are much more cost effective. You oryour client can find out if their prescription medication is name brand or generic (and the co-payment amount) by using the carrier’sWeb site Rx search. For your clients’ convenience, Web site addresses are included on the other side of this sheet.

Once the plan is approved and your clients’ employees have received their new membership cards:

• They should carry their membership card at all times. It is important for them to show their new ID card to their doctor during theirfirst visit after their new insurance plan becomes effective.

• Your clients should always make sure they use an in-network doctor or an in-network hospital in order to maximize their coverageand prevent significant gaps in coverage and/or higher out of pocket expenses.

• You should encourage your clients to review all of the benefit descriptions they received during enrollment including their Explanationof Benefits booklet (which the carrier mails to their home address) so they are familiar with their co-payments and covered procedures.

• Ensure they are aware of which procedures will require prior authorization in their plan documents. Remember that proceduresauthorized with their previous carrier may require pre-authorization with their new carrier. Each carrier has their own criteria, so anauthorization by one carrier does not guarantee authorization by another carrier in all circumstances.

• For any additional questions, your client should call Member Services (see other side of this sheet or their ID card for the phone number).

4

Contact Member Services for anyquestions or assistance

Northern California 800.255.9673 ■ Los Angeles 800.560.5614 ■ Inland Empire 877.225.0988 ■ Orange 800.869.6989 ■ San Diego 800.397.3381

* There are two categories of Blue Shield PPO plans: Blue Shield of California Shield Spectrum PPO plans (Shield Spectrum PPO) and Blue Shield of California Life & HealthPPO plans (Blue Shield Life PPO). They are filed differently with the state of California and there are differences in the networks. If you need to call PPO Member Servicesprior to receiving your new ID card and do not know which category of PPO you selected, please check with the person conducting your Enrollment Meeting, the companyinsurance contact person or your employer’s insurance agent.

** Third Party Administrator (TPA)

CARRIER or PLAN MEMBER SUPPORTBILINGUALSUPPORT

PROVIDERELIGIBILITY

VERIFICATION

INTERNET SUPPORT

Aetna® 888-702-3862 (HMO)888-802-3862,(PPO)

888-702-3862 (HMO)888-802-3862 (PPO)

888-632-3862 www.aetna.comwww.aetnanavigator.com

CaliforniaChoice® ** 800-558-8003 800-558-8003 Press #9 for Spanish

800-558-8003 www.calchoice.com

Kaiser Permanente® 800-464-4000 800-788-0616 800-464-4000 www.kaiserpermanente.org

Health Net® 800-361-3366 800-331-1777 800-361-3366 www.healthnet.com

Sharp 800-359-2002 800-359-2002 619-228-2490 www.sharphealthplan.com

HSA California® 866-251-4718 866-251-4718 Press #9 for Spanish

866-251-4718 Press #1

www.hsacalifornia.com

Kaiser PermanenteChoice Solution

800-580-9626 800-580-9626Press #9 for Spanish

800-580-9626 www.kpchoicesolution.com

Blue Shield of California 800-424-6521 (HMO)800-200-3242 (ShieldSpectrum PPO*)800-431-2809 (BlueShield Life PPO*)

800-248-5451 800-424-6521 (HMO)800-200-3242 (ShieldSpectrum PPO*)800-431-2809 (BlueShield Life PPO*)

www.mylifepath.com

California CPA ProtectPlus

Bunyan Consulting,LLC877-480-7923

Anthem Blue Cross –California Society ofCPAs 888-209-7847Select prompt # 2-5based on languagepreference

Anthem Blue Cross –California Society ofCPAs888-209-7847

www.cpaprotectplus.comwww.anthem.com/ca

HealthEdge Inc.Administrators **

Cost Saver Plan

Allied National ** 800-825-7531

Foundation for MedicalCare 800-334-7341Ask for Spanishspeaking Rep

Allied National ** 800-825-7531

www.alliednational.com(Note: HealthEdge Inc & theCost Saver Plan are notreferenced until you log in tothe secure member section)

PacifiCare®

A UnitedHealthcare®

Company

800-624-8822 (HMO)800-913-9133 (POS)866-316-9776 (PPO)

866-863-9776 www.pacificare.com800-624-8822 (HMO)800-913-9133 (POS)866-316-9776 (PPO)Follow prompts orask for interpreter800-730-7270 forSpanish only (PPO)

UnitedHealthcare® Call number on ID cardor Temporary ID cardprinted after registrationon www.myuhc.com

Call number on ID cardor Temporary ID cardprinted after registrationon www.myuhc.com

877-842-3210 www.myuhc.com

5

w w w. w o r d a n d b r o w n . c o m

Carrier Date of Billing Due Date Termination Date

Aetna 15th of the prior month 1st of the month End of the month

Aetna 15th Effective Date* 1st of the month 15th of the month 15th of the following month

Aflac 1st or 15th of the month 30 days after date of billing 30 days after due date

Anthem Blue Cross 7-8th of the prior month 1st of the month 30 days after due date

Blue Shield of California 15th of the prior month 1st of the month End of the month

Blue Shield of CA 15th eff. date* 1st of the month 15th of the month 15th of the following month

CaliforniaChoice® 1st week of the month prior20th of the month prior, 10%late fee assessed after the 12thof the month

Last business day of the month

California CPA 15th of the prior month 1st of the month 30 days after due date

HealthEdge Cost Saver 15th of the prior month 1st of the month End of the month

Health NetAssigned date by account rep(usually within the first 3 weeksof the prior month)

1st of the month End of the month

Health Net 15th effective date* Determined by Account rep Determined by Account rep Determined by Account rep

HSA California® 1st week of the month prior20th of the month prior, 10%late fee assessed after the 12thof the month


Kaiser Permanente 10th of the month prior 1st of the month 30 days after due date

Kaiser Permanente ChoiceSolution 1st week of the month prior

20th of the month prior, 10%late fee assessed after the 12thof the month


Sharp Health Plan 5th of the prior month 1st of the month End of the month

UnitedHealthcare/PacifiCare 2nd week of the prior month 1st of the month End of the month

UnitedHealthcare Call your Word & Brown representative 1st of the month End of the month

*These carriers will only offer 15th of the month effective dates if they are coming off a group plan that ends on the 15th

Carrier Billing Cycles

6


HEALTH PLAN COMPARISON CHART

CompositeRates

Domestic Partner

Coverage

Full-time Student

Max. Age/Min. Units

MedicarePrimary/

Secondary*

Available on all plansfor small group with

25+ enrolling CAemployees.

Maximum of 4 plansmay be offered whentaking composite rates

Yes—CA residentsonly. Aetna treatsdomestic partners

the same as spousesin accordance with

AB 2208

Maximum age: 24 (in CA)

Minimum units:12

2-50: Not available

Yes—domesticpartners are treated

as spouses inaccordance

with AB 2208

Maximum age: 24

Minimum units:12

Not available


as spouses in accordance

with AB 2208

Maximum age: 25

Minimum units:12

New in Business

Do your age 65+rates vary based onwhether Medicare is

Primary or Secondary?

If yes, do you requireproof of Medicare PartsA and B before givingthe 65+ employee the

lower Medicare primary rate?

If a 65+ employee ina Medicare primarygroup is not eligiblefor Medicare will yoube the Primary payor

on their claims?

Please see pages 12-13for information regarding

Creditable and Non-Creditable Overview

Minimum length oftime in business?

Payroll recordsrequired?

If yes, how long?

Copy of businesslicense?

Other documentsrequired?

Yes

Yes

Yes

2 life group: 60 days3+ group: on or priorto requested effective

date

A minimum of 1 runor from start date tocurrent, whichever is

greater

Call representative

Call representative

Yes

Yes

Yes

Call representative

Call representative

Call representative

Call representative

No

No

Six weeks prior to the effective date

with a minimum of 2 eligible employees

At least 2 weeks worth of payroll,

or a letter from anattorney or certifiedpublic accountant(CPA) listing the

names of allemployees and

number of hoursworked each week

Refer to other documents required

Call representative

51+

Yes—CA residentsonly. California CPA

treats domesticpartners the same

as spouses inaccordance with

AB 2208

Maximum age: Through age 24

Minimum units:9

Yes

No

No

Call representative

No—except when spouse is enrolled as an employee

No

Subscription Agreementwith CalCPA membership

number, or if not,currently a photocopy of

Society membershipapplication

Yes


the same as spousesin accordance with

AB 2208

Health NetAvailable on HMO, ELECT Open Access & POS with a

minimum of 10 enrolledemployees on a given plan. Not available for EnhancedChoice, Silver Choice, PPO,FlexNet, Hn Options and HnOptions Silver Subscribers

Maximum age:24

Minimum units:9

No

N/A

Yes

6 weeks prior to effective

date with minimum 2 eligible employees

DE-6 required unless notin business long enough

to have one. Then 6weeks of payroll prior tothe effective date for at least 2 employees and 2 weeks for all other employees. 2 weeks

of payroll for new hiresnot on DE-6 and to verify

wage discrepancies on DE-6

Acceptable ownershipdocumentation varies by

business structure—call Word & Brown

representative

Acceptable ownershipdocumentation varies

by business structure—call your Word & Brown

representative

AetnaBlue Shieldof California CaliforniaChoice® California CPA

HealthEdge Cost Saver

15+ enrolled

Dependents eligible to age 25

Full-time student not required

Yes

No minimum required

No

Call representative

No

No

First full payroll and first filed SQUTR

when available

Yes—CA residentsonly. Domestic

partners are treated the same as

spouses in accordance

with AB 2208

7



CompositeRates

Domestic Partner

Coverage

Full-time Student

Max. Age/Min. Units

New in Business

Not available

Yes—domesticpartners are

treated the same as spouses in accordance

with AB 2208

Maximum age:24

Minimum units:12

Not available

Yes—employers whooffer coverage for

spouses must offer equalbenefits for domesticpartners. Employer is

responsible for keepingevidence of

interdependence on file.Domestic partners and

their dependents are noteligible for

COBRA coverage

N/A

Sharp Health Plan treats domestic

partners the same as spouses in accordance

with AB 2208

Maximum age: 24

Minimum units:Use the definition offull-time student of

institution child is attending

Minimum length oftime in business?

Payroll recordsrequired?

If yes, how long?

Copy of businesslicense?

Other documentsrequired?

MedicarePrimary/

Secondary*Do your age 65+

rates vary based onwhether Medicare is

Primary or Secondary?

If yes, do you requireproof of Medicare PartsA and B before givingthe 65+ employee the

lower Medicare primary rate?

If a 65+ employee ina Medicare primarygroup is not eligiblefor Medicare will yoube the Primary payor

on their claims?

Please see pages 12-13for information regarding

Creditable and Non-Creditable Overview

No

N/A

Yes

45 days

Yes—6 weeks

Yes

Yes—refer to SHP website for details

N/A

Yes—when usingKaiser Permanente

network

On or prior to requested effective date

Yes—payroll records fromstart date to current with a

minimum of one week.Payroll records must includerun date, employee names,wages, withholdings, Social

Security numbers andsummary totals.

If Social Security numbersare missing, a copy of eachemployee’s W-4 is required

Depends on business entity—call yourWord & Brown representative

Depends on business entity—

call yourWord & Brown representative

No No

N/A

Yes

45 days





Not available

Yes—employers who offer coveragefor spouses must

offer equal benefits for

domestic partners

Maximum age:24

Minimum units:Determined by

Group/Employer

N/A

Yes—when usingKaiser Permanente

network

50% of previous calendar quarter.

If proves less, Kaiser Permanente

will recertify the groupupon the first renewal

Varies depending onwhen the business

was established but 1 month

may be acceptable

Yes

New group application, employee applications,

declination of coverage, andproprietor/partner/

corporate officer form

No

Not available

Yes—domesticpartners are

treated the same as spouses in accordance

with AB 2208

Maximum age: 25

Minimum units:12

No

N/A

Yes

2 life group: 60 days

3+ group:on or prior to

requested effective date

A minimum of 1 runor from start date tocurrent, whichever is

greater

Call representative

Call representative


Maximum age:25

Minimum units:12

Not available

Call yourWord & Brown representative

No

Although rates do notvary for Medicare

Primary/Secondary,members with Medicare

Primary must submitcopy of Medicare card to

verify parts A & B

Yes

Call yourWord & Brown representative

Yes—call yourWord & Brown representative




Maximum age:through age 25

Minimum units:12


UnitedHealthcare/PacifiCare

SharpHealth Plan

Kaiser Permanente

HSA California® UnitedHealthcare

8


On plans which includeout-of-network

benefits,are these paid

based on aLimited FeeSchedule

(LFS) or Usual,Customary &Reasonable

(UCR)?

LFS:MC $500 80/60

MC $1,000 70/50MC $750 80/50/50

MC $1,000 80/50/50MC $2,000 80/50/50

MC $2,500 75/50MC Basic

MC $10,000 100/50MC HDHP HSA $2,300

80/50MC HDHP HSA $3,000

100/50MC HDHP HSA $3,300

80/50MC HDHP HRA $3,000

80/50UCR:

MC $250 90/70MC $250 80/60PPO $500 90/70PPO $750 80/60OOS PPO $250OOS PPO $500

OOS PPO $1,000Indemnity

Blue Shield pays out-of-networkproviders at the same contracted

dollar amount that a PPO provider

would be paid for the same service. The member is

responsible for anybilled charges abovethis PPO contracted

dollar amount

HMO:N/A

PPO:Negotiated Fee

Wrap with Kaiser

Permanente

Aetna will accept the greater of 50%

eligible and aminimum of 8 enrolled

All plans are available

2-50 lives:Blue Shield

Single Option, Dual Option and

Suite Deal package: Yes*— a minimum of 5 or 50% of the total

active enrolledemployees (whicheveris greater) must enroll

with Blue Shield

When Active Choice or Shield Savings Plan4800 is offered as theonly Blue Shield plan

alongside anothercarrier’s HMO plan:

Minimum Blue Shieldenrollment is five

active employees or20% of overall enrolledemployees (whichever

is greater).

Blue Shield PlanSelect:

Yes*— a minimum of 5 or 75% of the

total active enrolledemployees (whicheveris greater) must enroll

with Blue Shield.

*SIGNED REFUSALREQUIRED FOR ALL

KAISER PERMANENTEENROLLEES

2-50 lives:

Not allowed


2+ lives:

HMOYes—do allow HMOwrap. Employees

covered by anotherHMO are not

counted as eligible

PPODo not allow

PPO wrap

LFS

Is the Deductible part of the

out-of-pocketMaximum?

No The deductible applies to the

out-of-pocket in all plans

HSA 1500* & HSA 2400*:

Yes

PPO 750, PPO 1000,& PPO 2400:

No

*HSA-Qualified HighDeductible Health Plan

HSA plans only

Maximum AllowableAmount 75th Percentile:

PPO 10 - Standard & ValuePOS 10,POS 20,

Value HSA 1500

LFS:PPO 20 - Standard & ValuePPO 30 - Standard & ValuePPO 40 - Standard & Value

Salud PPOValue HSA 2500Value HSA 3500Value HSA 4500

Standard HSA 2000Standard HSA 3000Standard HSA 4000

Options PPO 250, 500,1500, 1750,

Options PPO 3000/4000HSA Comp.

2-4 active enrolled: Not allowed

5 active enrolled:Hn Options packageonly. See below for

details.

6-50 active enrolled:

HMO & EOA*: Yes—on a single plan

choice basis. 50%with a minimum of 6

must enroll withHealth Net.

*Silver Network HMO plans areincluded in this

offering

POS & PPO: Yes—on a single plan choice basis.

75% with a minimum of 6 must

enroll with Health Net. Call

your Word & Brown representative for

details.

Enhanced Choice& Silver Choice: Yes—75% with a

minimum of 6 must enroll with Health Net

Hn Options & HnOptions Silver Choice

Min of 5 active enrolled with 75%

participation on somegroup health plan.

HSA plans only

AetnaBlue Shieldof California CaliforniaChoice® California CPA

UCR

2+ lives: If offered on a class

carve-out basis. Participation of 75%

of eligible in the classoffered Cost Saver

must be met

No

HealthEdge Cost SaverHealth Net

9



UCR—refer to Evidence of

Coverage for further details

Not applicable

All PPOs & POS:LFS (based on

National Medicare)

Sharp Health Companion PPO Plans

use a UCR schedule

POS or Dual Option:2-50 lives:

Not allowed

HMO, PPO or Multi Option:

2-9 lives: Not allowed

10-15 lives: Yes—a minimum of

10 (excludingCOBRA) must enroll

with PacifiCare.

16-50 lives: Yes—minimum 60% of eligible employees

must enroll withPacifiCare.

(For Multi ChoiceOption only Kaiser

Permanente HMO allowed)

2-9 enrolled: Not available

10-15 enrolled:Minimum 10 enrolled

16+: 50% or 10 enrolled

whichever is greater

On plans which includeout-of-network

benefits,are these paid

based on aLimited FeeSchedule

(LFS) or Usual,Customary &Reasonable

(UCR)?

Wrap with Kaiser

Permanente

HMO:N/A

POS:UCR

Not applicable

Is the Deductible part of the

out-of-pocketMaximum?

Limits apply. Call your

Word & Brown representative

HMO 20/$1,000, HDHP 1400, & HDHP 2400:

Yes

PPO 30/$500,PPO HSA 2200, POS 20/$1,000, POS 30/$1,500& Indemnity:

No

No for all products except forHMO plans with anannual deductible

HMO Plans:N/A

Sharp Health Companion PPO

Plans:No

HMO:N/A

PPO:Limited FeeSchedule

2-50 lives:

Not allowed

Yes—all plans

Call your Word & Brownrepresentative





SharpHealth Plan

Kaiser Permanente


10


N/A

N/A

Do any of your HSA-Compatible High Deductible

Health Plans(HDHP) have an

embedded*deductible withina family plan in

which anindividual family

member does not have to meetthe higher family

deductible ifhe/she has met

the lowerindividual

deductible?

Yes

*When HSA plans were first introduced in 2004, IRS publications used the term “embedded deductible” to refer to the individual deductiblewithin a family plan in which an individual family member does not have to meet the higher family deductible if he/she has met the lowerindividual deductible. Current IRS publications do not use the term “embedded deductible”.

IRS Publication 969 (2007) “Health Savings Accounts and Other Tax-Favored Health Plans” provides the following HDHP eligibility clarificationon page 4:

“Family plans that do not meet the high deductible rules. There are some family plans that have deductibles for both the family as a wholeand for individual family members. Under these plans, if you meet the individual deductible for one family member, you do not have to meetthe higher annual deductible amount for the family. If either the deductible for the family as a whole or the deductible for an individual familymember is below the minimum annual deductible for family coverage, the plan does not qualify as an HDHP.”

No

List each of your HSA-Compatible High Deductible

Health Plans(HDHP) with

an embedded*individualdeductible

CA MC $2300 80/50

CA MC $3000 100/50

CA MC $3300 80/50

Shield Savings Plan2500

Shield Savings Plan4800

N/A


N/A

NoYes No

N/A

HealthEdge Cost SaverHealth NetAetna

Blue Shieldof California CaliforniaChoice® California CPA

11


*When HSA plans were first introduced in 2004, IRS publications used the term “embedded deductible” to refer to the individual deductiblewithin a family plan in which an individual family member does not have to meet the higher family deductible if he/she has met the lowerindividual deductible. Current IRS publications do not use the term “embedded deductible”.

IRS Publication 969 (2007) “Health Savings Accounts and Other Tax-Favored Health Plans” provides the following HDHP eligibility clarificationon page 4:

“Family plans that do not meet the high deductible rules. There are some family plans that have deductibles for both the family as a whole andfor individual family members. Under these plans, if you meet the individual deductible for one family member, you do not have to meet thehigher annual deductible amount for the family. If either the deductible for the family as a whole or the deductible for an individual familymember is below the minimum annual deductible for family coverage, the plan does not qualify as an HDHP.”

Do any of your HSA-Compatible High Deductible

Health Plans(HDHP) have an

embedded*deductible withina family plan in

which anindividual family

member does not have to meetthe higher family

deductible ifhe/she has met

the lowerindividual

deductible?

List each of your HSA-Compatible High Deductible

Health Plans(HDHP) with

an embedded*individualdeductible

Yes

HMO 2600,HMO 2800B

Yes YesNoYes


PPO HSA 2200 UnitedHealthcare HSA Choice

Plus Plan D6-1

UnitedHealthcare HSA Choice

Plus Plan C3-X

N/A$0/$2,700 Deductible

Plan with HSA

$30/$2,700 Deductible

Plan with HSA



SharpHealth Plan

Kaiser Permanente




12*Applies to both Silver Network and Full Network plans.

Medicare Part D Prescription CoverageCreditable & Non-Creditable Overview by Health Plan

Creditable Coverage Prescription drug benefit with current plan from employer is at least as good as the pharmacy benefits offered through the new Medicare Part D standard planNon-creditable Coverage Prescription drug benefit with current plan from employer is not as good as the pharmacy benefits offered through the new Medicare Part D standard plan

CreditableCreditableNon

CreditableNon

Creditable

AetnaHMO

HMO $10 ■HMO $15 ■HMO $20 ■HMO $30 ■HMO $40 ■HMO Deductible $1,000 ■Health HMO HRA $750 $15/$30 ■Health HMO HRA $1,500 $25/$50 ■Aetna Value Network HMO $10 ■Aetna Value Network HMO $20 ■Aetna Value Network HMO $30 ■Aetna Value Network HMO $40 ■

PPO/EPOMC $250 90/70 ■MC $250 80/60 ■MC $500 80/60 ■MC $750 80/50/50 ■MC $1,000 80/50/50 ■MC $1,000 70/50 ■MC $2,000 80/50/50 ■MC $2,500 75/50 ■MC Basic ■MC $10,000 100/50 ■PPO $500 90/70 ■PPO $750 80/60 ■Aetna EPO 80 ■MC HDHP HSA $2,300 80/50 ■MC HDHP HSA $3,300 80/50 ■MC HDHP HSA $3,000 100/50 ■MC HDHP HRA $3,000 80/50 ■

IndemnityIndemnity ■

Blue ShieldHMO

Access+ HMO Plan 5 ■Access+ HMO Plan 10 ■Access+ HMO Plan 15 ■Access+ HMO Plan 20 ■Access+ HMO Value 20 ■Local Access+ HMO Plan 20 Value ■Access+ HMO Plan 25 ■Access+ HMO Plan 30 ■Local Access+ HMO Plan 30 ■Access+ HMO Plan 40 ■Access Baja HMO Plan 5 ■Access Baja HMO Plan 10 ■

PPOActive Choice Plan 500 SG ■Active Choice Plan 750 SG ■Shield Savings, Zero Deductible ■Shield Spectrum PPO Plan 250 Premier ■Shield Spectrum PPO Plan 250 Standard ■Shield Spectrum PPO Plan 500 Premier ■Shield Spectrum PPO Plan 500 Standard ■Shield Spectrum PPO Plan 500 Value ■Shield Spectrum PPO Plan 750 Value ■Shield Spectrum PPO Plan 1000 Value ■Shield Spectrum PPO Plan 1500 Value ■Shield Spectrum PPO Plan 2000 Value ■Shield Spectrum PPO Plan 1000 ■Shield Spectrum PPO Plan 3000 ■Shield Savings Plan 1800/3600 ■Shield Savings Plan 2000/4000 ■Shield Savings Plan 2250/4500 ■ Shield Savings Plan 2500 ■Shield Savings Plan 3000/6000 ■Shield Savings Plan 4800 ■

POSAdded Advantage POS ■

CaliforniaChoice®

HMOCalChoice® HMO 15 ■CalChoice® HMO 25 ■CalChoice® HMO 25 Value ■CalChoice® HMO 30 ■

CaliforniaChoice® (cont.)CalChoice® HMO 30 Value ■CalChoice® HMO 40 ■CalChoice® HMO 40 Value ■Elect Open Access 25 ■Salud HMO y mas ■

PPO CalChoice® PPO 750 ■CalChoice® PPO 1000 ■CalChoice® PPO 2400 ■

Consumer Directed Plans Active ChoiceSM 500 ■

HSA-Compatible CalChoice® HSA 1500 ■CalChoice® HSA 2400 ■

California CPAHMO

HMO Advantage 100 ■HMO Value 80 ■

PPO ProtectPlus 10 ■ProtectPlus 15 ■ProtectPlus 15 Enhanced ■ProtectPlus 25 ■ProtectPlus 25 Enhanced ■ProtectPlus 35 ■ProtectPlus 35 Enhanced ■ProtectPlus 45 ■

HSA-CompatibleProtect HSA ■

Health NetHMO/EPO

HMO 10 Standard & Value* ■HMO 20 Standard & Value* ■HMO 30 Standard & Value* ■HMO 40 Standard* ■HMO 40 Value* ■EOA 10 Standard & Value ■EOA 20 Standard & Value ■EOA 30 Standard & Value ■EOA 40 Standard ■EOA 40 Value ■EOA Silver HMO 10* ■EOA Silver HMO 20* ■EOA Silver HMO 30* ■EOA Silver HMO 40* ■Options HMO 25 ■Options HMO 35 ■Options EOA 25 ■Options EOA 35

POS POS 10 ■POS 20 ■

PPOPPO 10 Standard & Value ■PPO 20 Standard & Value ■PPO 30 Standard & Value ■PPO 40 Standard ■PPO 40 Value ■Flex Net ■HMO Conversion ■Value HSA 1500 ■Value HSA 2500 ■Value HSA 3500 (if Medicare secondary) ■Value HSA 4500 (if Medicare secondary) ■Standard HSA 2000 (if Medicare secondary) ■Standard HSA 3000 (if Medicare secondary) ■Standard HSA 4000 (if Medicare secondary) ■Options PPO 250 ■Options PPO 500 ■Options PPO 1500 ■Options PPO 1750 ■Options PPO HSA 3000 (if Medicare secondary) ■Options PPO HSA 4000 (if Medicare secondary) ■HRA 3000 (if Medicare secondary) ■HRA 5000 (if Medicare secondary) ■

Medicare Part D Prescription CoverageCreditable & Non-Creditable Overview by Health Plan

Creditable Coverage Prescription drug benefit with current plan from employer is at least as good as the pharmacy benefits offered through the new Medicare Part D standard planNon-creditable Coverage Prescription drug benefit with current plan from employer is not as good as the pharmacy benefits offered through the new Medicare Part D standard plan

CreditableNon

CreditableCreditableNon

Creditable

HSA California®

HMO/EPOHMO 1800 ■HMO 2200 ■HMO 2600 ■HMO 2800B ■

PPOPPO 2500 (if Medicare secondary) ■PPO 3500 (if Medicare secondary) ■PPO 4500 (if Medicare secondary) ■

Kaiser PermanenteHMO/EPO

$5 Copayment Plan ■$15 Copayment Plan ■$20 Copayment Plan ■$30 Copayment Plan ■$50 Copayment Plan ■$30/$1000 Deductible Plan ■$30/$1500 Deductible Plan ■

PPO$40/$1000 PPO Plan ■

POS$35 POS Plan ■

HSA-Compatible$40/$2,500 Deductible Plan with HSA ■$30/$2,700 Deductible Plan with HSA ■$0/$2,700 Deductible Plan with HSA ■$0/$1,500 Deductible Plan with HSA ■$0/$2,200 HSA Comp plan ■

Kaiser Permanente Choice SolutionHMO

HMO 10 ■HMO 30 ■HMO 20/$1,000 ■

PPOPPO 30/$500 ■PPO HSA 2200 ■

POSPOS 20/$1,000 ■POS 30/$1,500 ■

Indemnity Indemnity ■

HSA-CompatibleHDHP 1400 ■HDHP 2400 ■

Sharp Health PlanHMO

Blue Plan 10/10/0 ■Blue Plan 15/15/250 ■Blue Plan 20/30/500 ■Blue Plan 20/40/1000 ■Blue Plan 30/40/1000 ■Blue Plan 30/40/750/day ■Blue Plan 40/40/750/day ■Gold Plan 10/10/0 ■Gold Plan 15/15/250 ■Gold Plan 20/30/500 ■Gold Plan 20/40/1000 ■Gold Plan 30/40/1000 ■Gold Plan 30/40/750/day ■Gold Plan 40/40/750/day ■

PPO Companion PlansCompanion Plan 1 20/500/80/50 ■Companion Plan 2 30/1000/80/50 ■

UnitedHealthcare/PacifiCareHMO/EPO

SignatureValue 10-30/100 ■SignatureValue 15-30/250a ■SignatureValue 20-40/500d ■SignatureValue 35/600d ■SignatureValue 10/500d ■SignatureValue 20/1500ded ■SignatureValue Advantage 10/500d ■SignatureValue Advantage 20/1500ded ■SignatureValue Advantage 35/600d ■SignatureValue™ Advantage 40-60/2000ded ■SignatureValue™ 10-30/500d ■SignatureValue™ 15-30/300a ■SignatureValue™ 20-40/1500d ■SignatureValue™ 10-30/100 Advantage ■SignatureValue™ 10-30/500d Advantage ■SignatureValue™ 15-30/300a Advantage ■SignatureValue™ 20-40/1500d Advantage ■SignatureValue™ 20-40/500d Advantage ■SignatureValue™ 35-45/600d Advantage ■HCP Network HMO 25-50/500 ded. ■HCP Network HMO 25-75/1500 ded. ■HCP Network HMO 25-75/500 ded. ■

PPOSignatureOptions™ 15/80-60 ■SignatureOptions™ 20/90-50/250 ■SignatureOptions™ 30/80-60/250 ■SignatureOptions™ 30/80-60/500 ■SignatureOptions™ 40/50-50/1000 ■SignatureOptions™ 40/70-50/1000 ■SignatureOptions™ 40/70-50/250 ■SignatureOptions™ 70-50/2000 ■SignatureOptions™ 70-50/3500 ■

POSSignaturePOS 15/80-60 ■

UnitedHealthcarePPO

Choice Plus PPO 20/250/90% (C3-J) ■Choice Plus PPO 30/500/80% (C3-M) ■Choice Plus PPO 40/500/70% (C3-R) ■Choice Plus Balanced PPO 20/3000/90% (C3-I) ■Choice Plus Balanced PPO 30/1000/80% (C3-K) ■Choice Plus Balanced PPO 30/2500/80% (C3-L) ■Choice Plus Balanced PPO 40/1000/70% (C3-P) ■Choice Plus Balanced PPO 40/1500/70% (C3-Q) ■Choice Plus Balanced PPO 40/1000/50% (C3-N) ■Choice Plus Balanced PPO 40/2000/50% (C3-0) ■Choice Plus Bal. Value PPO 20/3000/90% (D6-L) ■Choice Plus Bal. Value PPO 30/1000/80% (D6-M) ■Choice Plus Bal. Value PPO 30/2500/80% (D6-N) ■Choice Plus Bal. Value PPO 40/1000/70% (D6-Q) ■Choice Plus Bal. Value PPO 40/1500/70% (D6-R) ■Choice Plus Bal. Value PPO 40/1000/50% (D6-0) ■Choice Plus Bal. Value PPO 40/2000/50% (D6-P) ■Non-Differential PPO 2000/80% (6H-F) ■

HSA-CompatibleChoice Plus Definity HSA 2000/100% (D6-K) ■Choice Plus Definity HSA 1500/80% (C3-Z) ■Choice Plus Definity HSA (embedded) 2850/80% (D6-I) ■Choice Plus Definity HSA 2850/80% (D6-J) ■Choice Plus Definity HSA (embedded) 3000/70% (C3-X) ■Choice Plus Definity HSA 3500/70% (C3-Y) ■

HRA-CompatibleChoice Plus Definity HRA 2000/90% (C3-W) ■Choice Plus Definity HRA 1500/80% (C3-U) ■Choice Plus Definity HRA 2500/80% (C3-V) ■Choice Plus Definity HRA 2000/70% (C3-S) ■Choice Plus Definity HRA 3000/70% (C3-T) ■

13

14


Broker of Record Change Requirements—California Medical Carriers

CARRIERNAME

NEED ORIGINALBOR CHANGELETTER ONCOMPANY

LETTERHEAD ORCOPY OK?

SEND BROKER OFRECORD CHANGE

LETTER TO(DEPT NAME + FAX

# OR MAILINGADDRESS)

TURN AROUNDTIME FOR

PROCESSING THIS CHANGE

DOES CARRIERNOTIFY EXISTINGBROKER OF THIS

REQUESTEDCHANGE?

EFFECTIVE DATEFOR NEW BROKERIF GROUP DOES

NOT RESCIND THISCHANGE REQUEST

IS PRIOR AGENTVESTED? IF YES,

HOW LONG

IS GA VESTED? IF YES, HOW

LONG?

Aetna Copy Sales Support888-258-4530

7-10business days No Date of

processing No Life of plan

AnthemBlue Cross Copy

Sales Support Attn: Mia/Vanessa

805-713-71913-4 Weeks Yes 1st of following

month No Life of plan

Blue Shield ofCalifornia Copy Producer Services

209-367-64897-14

Business Days Yes 1st of followingmonth No Life of plan

CaliforniaChoice®

Copy Finance714-972-7368

7-14 Business Days

(15 day rescission period)

Yes 1st of followingmonth

Yes—for the first 6

monthsLife of plan

California CPA*

*Broker of Recordchanges apply to

Word & Brown agentsbusiness ONLY

Copy or fax of letter isrequired

Effective 11/1/09:Banyan Consulting, LLCAttn: Tom Zimmerman

1215 Manor Drive, Suite 200

Mechanicsburg, PA17055

FAX 877-237-4519Phone 877-480-7923

Banyan Consulting,LLC will recognize the BOR change the first of the

following month upon receipt

from Word & Brown

prior to the 15th of the current month

Yes

1st of followingmonth upon receipt from

Word & Brownprior to the 15th of the current

month

No

Yes—as long asCPA firm continues

participation in the Group

Insurance Trust

HealthEdge Original onletterhead

Sales & Marketing661-616-4889 1 week Yes 1st of following

month 1st year Life of plan

Health Net Copy

AccountManagement:

So. Cal Fax 818-676-6297No. Cal Fax

800-303-3110

7-10 Business Days Yes 1st of following


HSA California® Copy Finance714-972-7368

7-14 Business Days

(15 day rescission period)

Yes 1st of followingmonth


monthsLife of plan

Kaiser Permanente Copy

BrokerAdministration 800-440-2323

Fax626-405-5947

14 Business Days Yes 1st of following


Kaiser Permanente

Choice Solution

Copy Finance714-972-7368


month


monthsLife of plan

Sharp Copy Sales and Marketing619-228-2446

7-10 Business Days Yes

1st of followingmonth unless

requested during the 1st week of

month to be effective that month

No Life of plan

UnitedHealthcare/PacifiCare Copy

AccountManagement800-926-2951



UnitedHealthcare CopyCall your

Word & Brownrepresentative


Yes 1st of followingmonth No Life of plan

15


HPV Vaccine Summary by Carrier

Quadrivalent HPV VaccineBrand Name: Gardasil

GARDASIL is a vaccine against the HPV or Human Papillomavirus. The GARDASIL vaccine protects recipients against 4 typesof HPV, including the two types that cause most cervical cancers and the two types that cause the most genital warts.

GARDASIL is for girls and women ages 9 to 26. GARDASIL works when given before you have any contact with HPV Types 6,11, 16, and 18.

GARDASIL will be given as a three dose series completed over 6 months.

The retail price of the vaccine is $120 per dose ($360 for full series).

Federal health programs such as Vaccines for Children (VFC) will cover the HPV vaccine. The VFC program provides freevaccines to children and teens under 19 years of age, who are either uninsured, Medicaid-eligible, American Indian, or AlaskaNative. There are over 45,000 sites that provide VFC vaccines, including hospitals, private clinics, and public clinics. The VFCProgram also allows children and teens to get VFC vaccines through Federally Qualified Health Centers or Rural HealthCenters, if their private health insurance does not cover the vaccine.

Answers to frequently asked questions about the vaccine:

X - Approved under Medical Benefit rather than Prescription Drug because it is a vaccine series administered by a physician.PA - Prior authorization required

Carrier Status

Aetna X

Blue Shield of California X

CaliforniaChoice® X

California CPA X

HealthEdge Cost Saver X

Health Net X

HSA California® X

Kaiser Permanente X

Kaiser Permanente Choice Solution X

Sharp Health Plan X

UnitedHealthcare/PacifiCare X

UnitedHealthcare X

16

Health PlanUpdate


Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignmentguidelines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect whenyou submit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to changeat the carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no smallgroup (2-50) can receive an RAF lower than 0.90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).

RAF ASSIGNMENT BY GROUP SIZE

& SPECIAL RAF REDUCTION PROGRAMS

2-4 Automatic 1.10 RAF7/1/09 – 12/31/09

5-9 Enrolling employeeswill be medicallyunderwritten to

determine their RAF

7/1/09 – 12/31/09

EffectiveDates

Group Size (based on number ofenrolling employees)

RAF ReductionOffer

Program Rules & Eligibility Criteria Checklist

★★★ Special RAF Reduction Program ★★★

RAF Assignment by Group Size*(based on number of enrolling employees)

2-4 ➢ Automatic 1.105-9 ➢ Minimum .90 - Maximum 1.10

10-50 ➢ Minimum .90 - Maximum 1.10

AETNA

Maximum .90 RAFif group meets

program rules &eligibility criteria

7/1/09 – 12/31/09

*These are the RAF assignment guidelines for groups that do not qualify for the Special RAF Reduction Program outlined below.

10-50

• Groups coming from a large group contract that are AB1672 eligibleare eligible if they can provide a large group renewal of less than a20% increase within 90 days of their requested effective date

• Carve out groups (management/non-management, union/non-union)are not eligible for RAF promotion

• Groups must submit a copy of both their current and last year’srenewal or their issued RAF at new business

• Groups that received a 10-point increase in their RAF are ineligible forthis promotion

• Groups applying for the guaranteed RAF must be AB 1672 eligible andhave a current RAF of 1.06 or less with their current carrier

• This underwriting offer does not apply to groups enrolled withCaliforniaChoice®, Contractor’s Choice, HSA California® or KaiserPermanente Choice Solution, or groups that have withdrawn fromAetna within 12 months of the requested effective date

• COBRA/CalCOBRA enrollees do not count toward the enrolledemployee counts

• Groups with no prior coverage do not qualify• If a group meets the RAF promotion guidelines, no health statements

required• To qualify for RAF reduction specials, the prior carrier renewal must

be the original renewal—not a revised renewal

Maximum .90 RAF if group meets


7/1/09 – 12/31/09 Downsized large group nowunder 50 eligible employees

Health PlanUpdate

17





EffectiveDates


RAF ReductionOffer

Program Rules & Eligibility Criteria ChecklistRAF Program for Groups Not Selecting the

“Suite Deal” Package


*These are the RAF assignment guidelines for groups that do not qualify for the Special RAF Reduction Program outlined below or on the following pages.

RAF Assignment by Group Size*(based on number of enrolling employees)2-5 ➢ Minimum 1.00 - Maximum 1.106-9 ➢ Minimum .95 - Maximum 1.10


BLUE SHIELD OF CALIFORNIA

6-9 10-pointRAF reductionif group meets


• Group must have a renewal RAF of 1.05 or lower to qualify for thisRAF program

• Must provide original copy of current health carrier renewal letterwith initial group enrollment

• No health statements or employer questionnaires• If Blue Shield cannot validate employee eligibility based on

documents provided then standard underwriting guidelines apply• Program applies to guaranteed-issue small groups only • Groups must meet standard underwriting guidelines (i.e. contribution

and participation) and submit the most recent quarter DE-6 and/orother required documentation to verify employee eligibility

• Sole proprietor, partner or corporate officer statement (C15293) isrequired on officers/owners who are not listed on the DE-6

• Standard underwriting guidelines apply to non-guaranteed issue groups or groups that do not qualify

• This program does not apply to groups that do not currently have coverage, groups that are not eligible for guaranteed acceptance, groups coming off of a “special deal” or association plan, or groups currently enrolled with CaliforniaChoice®

• Groups are eligible for the RAF reduction two months (60 days) beforetheir renewal date to two months (60 days) after their renewal date

• Risk Adjustment Factors are adjusted to the nearest .025 increment• The lowest RAF available is .90. For example: if a group has a

renewing RAF of .95, it will receive only a .90 RAF from Blue Shield• Groups may apply for a lower RAF via standard underwriting

guidelines and the submission of health questionnaires• The RAF reduction is a first-year reduction to the RAF for new small

group medical plans only• To qualify for RAF reduction specials, the prior carrier renewal must

be the original renewal - not a revised renewal

7/1/09 – 12/31/09

10+ Guaranteed .90 RAF ifgroup meets program

rules & eligibilitycriteria

7/1/09 – 12/31/09

See the following pages for additional Blue Shield RAF Reduction Programs

Note: Groups with employees enrolling in plans that are permissible to pair with a wrap product are not eligible for the RAFprogram. This exclusion applies whether the plans are offered as standalone or as part of any package. These plans areShield Savings Plan 1800/3600, Shield Savings Plan 2250/4500 and Shield Spectrum PPO Plan 3000.

18

Health PlanUpdate





EffectiveDates


RAF ReductionOffer

Program Rules & Eligibility Criteria Checklist“Suite Deal” RAF Program for Groups

With Current Coverage


*These are the RAF assignment guidelines for groups that do not qualify for the Special RAF Reduction Program outlined below or on the previous or following pages.




6-9 10-pointRAF reductionif group meets


• This RAF promotion is only available to new groups with current coverage thatselect the “Suite Deal” package

• Group must have a renewal RAF of 1.05 or lower to qualify for this RAF program• Must provide original copy of current health carrier renewal letter• No health statements or employer questionnaires• If Blue Shield cannot validate employee eligibility based on documents

provided then standard underwriting guidelines apply• Program applies to guaranteed-issue small groups only • Groups must meet standard underwriting guidelines (i.e. contribution

and participation) and submit the most recent quarter DE-6 and/or otherrequired documentation to verify employee eligibility

• Sole proprietor, partner or corporate officer statement (C15293) is required onofficers/owners who are not listed on the DE-6

• Standard underwriting guidelines apply to non-guaranteed issue groups orgroups that do not qualify

• This program does not apply to groups that do not currently have coverage,groups that are not eligible for guaranteed acceptance, groups coming off of a “special deal” or association plan, or groups currently enrolled withCaliforniaChoice®

• Applies to groups within 9 months of their most recent renewal. This programextends the eligibility of the renewal RAF letter from the prior carrier from 60days to nine months. This RAF promotion extension is only available for newgroups that select the “Suite Deal” package

• Groups must have 6 to 50 enrolling employees to qualify for the RAF program• Risk Adjustment Factors are adjusted to the nearest .025 increment• The lowest RAF available is .90. For example: if a group has a renewing RAF of

.95, it will receive only a .90 RAF from Blue Shield• Groups may apply for a lower RAF via standard underwriting guidelines and

the submission of health questionnaires• The RAF reduction is a first-year reduction to the RAF for new small group

medical plans only• Group must maintain at least 75% of renewal enrollment in order to qualify for

RAF reduction. (Applies to the “Suite Deal” RAF program only—not thestandard RAF program.)

• To qualify for RAF reduction specials, the prior carrier renewal must be theoriginal renewal - not a revised renewal

7/1/09 – 12/31/09



7/1/09 – 12/31/09

See previous and following pages for additional Blue Shield RAF Reduction Programs

Note: Groups with employees enrolling in plans that are permissible to pair with a wrap product are not eligible for the RAF program. This exclusion applieswhether the plans are offered as standalone or as part of any package. These plans are Shield Savings Plan 1800/3600, Shield Savings Plan 2250/4500 and ShieldSpectrum PPO Plan 3000.

Health PlanUpdate

19





EffectiveDates


RAF ReductionOffer

Program Rules & Eligibility Criteria Checklist“Suite Deal” RAF Program for Groups

With No Prior Coverage


*These are the RAF assignment guidelines for groups that do not qualify for the Special RAF Reduction Program outlined below or on the previous pages.




6-9 Guaranteed 1.00 RAFif group meets


• This RAF promotion is only available to new groups with no prior coveragethat select the “Suite Deal” package

• “Groups with no prior coverage” is defined as a group in business for oneyear or more with no prior coverage for at least 12 months, or a group inbusiness for less than a year that meets the Blue Shield interpretation ofAB1672 and has no prior group coverage

• No health statements or employer questionnaires• If Blue Shield cannot validate employee eligibility based on

documents provided then standard underwriting guidelines apply• Program applies to guaranteed-issue small groups only • Groups must meet standard underwriting guidelines (i.e. contribution

and participation) and submit the most recent quarter DE-6 and/or otherrequired documentation to verify employee eligibility

• Sole proprietor, partner or corporate officer statement (C15293) is required onofficers/owners who are not listed on the DE-6

• Standard underwriting guidelines apply to non-guaranteed issue groups orgroups that do not qualify

• Groups must have 6 to 50 enrolling employees to qualify for the RAF program• Risk Adjustment Factors are adjusted to the nearest .025 increment• The lowest RAF available is .90 • Groups may apply for a lower RAF via standard underwriting guidelines and

the submission of health questionnaires• The RAF reduction is a first-year reduction to the RAF for new small group

medical plans only

7/1/09 – 12/31/09



7/1/09 – 12/31/09

See previous pages for additional Blue Shield RAF Reduction Programs

20

Health PlanUpdate




RAF Assignment by Group Size(based on number of medically enrolling employees)

2-4 ➢ Automatic 1.105-14 ➢ Automatic 1.0015-50 ➢ 0.90* or 1.00

CALIFORNIACHOICE®

* To qualify for 0.90 RAF group must meet the following criteria:• Must submit a copy of their current renewal RAF statement from their current carrier showing a renewal RAF of 1.00 or less• Renewal statement must be within 3 effective dates of their CaliforniaChoice® requested effective date determined by underwriting



None Currently in Progress

21

Health PlanUpdate





HEALTH NET

EffectiveDates


RAF ReductionOffer



Guaranteed .95 RAFif group meets


• To qualify must be new AB1672 group of 6-50 enrolling employees with a current competitor renewal RAF of 1.06 or lower

• Effective date with Health Net of 1/1/09 – 12/31/09• Group’s renewal must be within 3 effective dates of their original

effective date with Health Net (i.e. January 1 Health Net group whoseother carrier renewal day falls between October 1 and April 1)

• Must submit copy of their current carrier renewal at the time of casesubmission

• Must have minimum of 6 qualifying new subscribers (excludingCalCOBRA and COBRA enrollees) who are effective with the groupon the date the group becomes effective

• Current CaliforniaChoice®, Contractor’s Choice, HSA California®,Kaiser Permanente Choice Solution, existing Health Net groups, andgroups under an association affiliation are not eligible

• Non-guaranteed issue groups are not eligible• New groups of 6-9 enrolling employees can submit Health

Statements to try for a lower rate – standard underwriting guidelineswill apply

• RAF guarantee is for the full 12-month contract period• All other standard paperwork and Underwriting rules apply• If group with SIC code on the Health Net industry load or discount

list is eligible for this RAF program then the normal industry load ordiscount does not apply

• For groups applying for a lower RAF, standard underwritingguidelines apply

1/1/09 – 12/31/09 6-9

Guaranteed .90 RAFIf group meets


1/1/09 – 12/31/09 10-50

*These are the RAF assignment guidelines for groups that do not qualify for the 2009 RAF Reduction Program outlined below.


2-5 ➢ Automatic 1.10 (could qualify for a 1.00 RAF if in a discounted industry and have clean health questionnaires)6-9 ➢ Minimum .90 with Individual Health Statements - Maximum 1.10


Health PlanUpdate




RAF Assignment by Group Size

N/A

HEALTHEDGE




22

Health PlanUpdate


Each carrier’s Underwriting Department assigns the final Risk Adjustment Factor (RAF) for each group based upon their own RAF assignment guide-lines and current special RAF reduction program (if any). This information is intended for use as a guide to help you know what to expect when yousubmit a group that meets the carrier’s eligibility criteria. RAF assignment procedures and special RAF reduction programs are subject to change atthe carriers’ discretion. Word & Brown cannot guarantee what RAF a carrier will give a particular group. According to California law, no small group(2-50) can receive an RAF lower than .90, or higher than 1.10, based on the carrier’s standard risk rates (1.00).




RAF Assignment by Group Size(based on number of medically enrolling employees)

2-4 ➢ Automatic 1.105-14 ➢ Automatic 1.0015-50 ➢ 0.90* or 1.00

HSA CALIFORNIA®

* To qualify for 0.90 RAF group must meet the following criteria:• Must submit a copy of their current renewal RAF statement from their current carrier showing a renewal RAF of 1.00 or less• Renewal statement must be within 3 effective dates of their HSA California requested effective date determined by underwriting


23

Health PlanUpdate






RAF Assignment by Group Size (based on number of enrolling employees)

2-5 ➢ Automatic 1.106-15 ➢ Automatic 1.00

16-50 ➢ Automatic .90**

KAISER PERMANENTE

Existing Kaiser Permanente & CaliforniaChoice® groups are considered a spin-off(formerly known as breakaway) and should be issued the same RAF as the purchaser they spin-off of.

** Groups of 16-50 receive a .90 RAF if 75% are new members to Kaiser Permanente


24

Health PlanUpdate



RAF ASSIGNMENT BY GROUP SIZE & SPECIAL RAF REDUCTION PROGRAMS

1-5Less than 10 NA

KAISER PERMANENTE CHOICE SOLUTION

The following information defines what Risk Adjusted Factor (RAF) is applied to the rates quoted:• Groups with 2-5 employees are always quoted 1.10.• Groups with 6-50 employees are quoted with the 1.00 RAF before the final RAF is applied in underwriting.

Note: Life only employees and COBRA members are not included in the overall employee count.

1.10

1-40

6-40

10 or more

10 or more

Less than 10

11-15

16+

NA

1.00

0.90

Most recently assigned KaiserPermanente RAF (0.95 and 1.05

will be rounded to 1.00)


# of employees currently enrolledin Kaiser Permanente

# of employees ADDED throughKaiser Permanente Choice Solution

TOTAL number of employeesenrolled in Kaiser Permanente

Choice Solution

Final RAF appliedduring Underwriting

Total number of employees enrolled in Kaiser Permanente Choice Solution Final RAF applied during underwriting

2 - 5

6 - 15

16 - 50

1.10

1.00

0.90


The following table defines how the RAF is applied during underwriting for groups who do not currently have existing coverage withKaiser Permanente or CaliforniaChoice® within 12 months of the effective date:

The following table defines how the RAF is applied during underwriting for groups who currently have existing coverage withKaiser Permanente or CaliforniaChoice® within 12 months of the effective date:

25

Health PlanUpdate





RAF Assignment by Group Size*(based on number of enrolled employees)

2-5 ➢ Automatic 1.106-50 ➢ Minimum .90 – Maximum 1.10

SHARP HEALTH PLAN

Individual health statements are required for groups of 2-24 enrolled subscribers. Group questionnaire is required for groups of 25-50 enrolled subscribers.


2-5 enrolling employees Automatic 1.10 RAF • No health questionnaires or employer questionnaire required if allprogram criteria is met

• All groups applying for the RAF discount must be AB1672 eligible;standard underwriting guidelines apply to non-guaranteed issuegroups, to include the submission of health questionnaires.

• Groups must have a current RAF of 1.06 or less with their currentcarrier

• Group must submit a copy of their current carrier renewal reflectingthe renewal date and renewal RAF upon submission to Sharp HealthPlan. The renewal date reflected must be within 2 months of therequested Sharp Health Plan effective date

• Groups that received a 10 point increase in their RAF at renewal areineligible for this promotion

• COBRA enrollees do not count toward the enrolled employee counts• Groups with no prior group coverage are ineligible for this promotion• This offer does not apply to groups enrolled with CaliforniaChoice® ,

Contractor’s Choice, HSA California®, Kaiser Permanente ChoiceSolution, or who have withdrawn/terminated from Sharp Health Planwithin 12 months of the requested effective date

• Groups must meet all standard underwriting guidelines• The RAF promotion is a first-year reduction only for new small group

business• Groups of 6-9 may apply for a lower RAF via standard underwriting

guidelines, to include the submission of health questionnaires• PPO questionnaires required but RAF reduction automatically

applies as long as program criteria and participation requirementsare met.

• Out of service area or out of state employees enrolling in the PPOwill always be at a 1.0 RAF, and do not count towards in service areaparticipation requirements for the RAF reduction program. Pleaserefer to standard underwriting guidelines.

1/1/09 – 12/1/09

6-9 enrolling employees Guaranteed .95 RAFif group meets program

rules & eligibility criteria

1/1/09 – 12/1/09

EffectiveDates


RAF ReductionOffer


10-50 enrolling employees Guaranteed .90 RAF if group meets program

rules & eligibility criteria

1/1/09 – 12/1/09

26





Health PlanUpdate

UNITEDHEALTHCARE/PACIFICARE

6-50 Guaranteed .90 RAF without medical

questions if groupmeets program rules & eligibility criteria

• Groups coming from a large group contract that are now AB1672-eligible canqualify for the RAF promotion if they can provide a large group renewal ofless than 20% increase within three months of their requested effective date.New group must submit a copy of its current carrier renewal reflecting theRAF/renewal census and documentation from its current carrier disclosingthe amount of the RAF change with the group's initial submission

• Groups must meet Small Group eligibility requirements (AB1672)• Guaranteed .90 RAF for groups with prior carrier RAF of 1.06 or better• CalCOBRA/COBRA enrollees do not count toward group size• Groups must be enrolling with PacifiCare and/or UnitedHealthcare for

October 1, 2009 - December 31, 2009 effective dates• New groups must present a prior carrier small group renewal that reflects a

renewal date within 3 months of the new business effective date withPacifiCare or UnitedHealthcare Plans

• New group must submit a copy of its current carrier small group renewalreflecting the RAF with the group’s initial submission

• When the current carrier small group renewal does not reflect the enrolledcensus, include copy of the current carrier’s most recentbilling statement

• All other paperwork and underwriting guidelines apply (i.e. participation,employer contribution, wage and tax information, etc.)

• New groups of 2-5 active enrolling employees are not eligible for this RAFProgram

• Groups that receive a 10-point increase on their renewal with another carrierdo not qualify

• Group’s current carrier renewal census must match the enrolling employeesin PC/UHC

• CaliforniaChoice®, Contractor’s Choice, HSA California®, Kaiser PermanenteChoice Solution, existing PC/UHC groups, Non-GI and Association cases arenot eligible

• Groups with enrollment in more than one medical carrier must meet all of theabove requirements

10/1/09 – 12/31/09

EffectiveDates


RAF ReductionOffer



27


1) Less than 3 enrolled employees: 1.102) Groups of 3 enrolled employees: 1.00-1.103) Groups of 4 enrolled employees: .95-1.104) 5+ enrolled employees: .90-1.10

WORKSITEVOLUNTARYPRODUCTS


29

31


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

NY

VAWVA

MD

DE

NJ

MA

ME

NH

VT

CT RI

Customer Service, Bilingual Support,& Broker Services800-99-AFLAC800-SI-AFLAC (Spanish)Commissions Please contact your Aflac representativeClaimsAmerican Family Life Assurance Companyof Columbus (Aflac)Worldwide Headquarters1932 Wynnton RoadColumbus, GA 31999-7251800-99-AFLACFax (Add-ons/Deletes)877-44-AFLAC

California Coverage Area:All of California is covered. Plans areindemnity policies and pay all benefitsto policy holder unless assigned

U.S. Coverage Area:The entire U.S. is covered. Plans areindemnity policies and pay all benefitsto policy holder unless assigned

32


OUT-OF-STATE COVERAGE

PRODUCTS OFFERED

Is Coverage Offered for Out-of-State employees?

What is the minimum % of employees required in CA?

What plans (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 rates for Out-of-State employees based on theCA Employer Zip code or based on Out-of-State ZipCode (and separate rates)?

Any other rules, restrictions or guidelines not mentioned:

Yes

N/A; 3 or more policy holders.

All States are allowedCall your Word & Brown representative

The rates are based on SIC of Company

All plan types

Policy: AccidentFeatures:

• Emergency Treatment Benefit• Specific-Sum Injuries Benefit• Accidental-Death Benefit• Initial Hospitalization Benefit

Policy: Short-Term DisabilityFeatures:

• Selection of:■ Monthly benefit amount■ Elimination Period■ Benefit Period

• Guaranteed-renewable to age 70• Benefits paid directly to policy holder unless chosen otherwise• Benefits paid regardless of any other insurance

Policy: Cancer/Specified-DiseaseFeatures:

• First-Occurrence Benefit• Hospital Confinement Benefit• Radiation and Chemotherapy Benefit• Cancer Screening Wellness Benefit• Ambulance transportation and lodging benefits• Surgical/Anesthesia Benefit

Policy: Hospital Confinement IndemnityFeatures:

• Hospital Confinement Benefit• Rehabilitation Unit Benefit• Surgical Benefit

Policy: Specified Health BenefitFeatures:

• Pays a First-Occurrence Benefit as well as Hospital Confinement and Continuing Care Benefits for:■ Heart attack & coronary artery bypass surgery■ Stroke■ End-stage renal failure■ Major human organ transplant■ Major third-degree burns■ Coma■ Paralysis

Policy: Hospital Intensive CareFeatures:

• Daily ICU Confinement Benefit• Daily Subacute Unit Confinement Benefit

Policy: DentalFeatures:

• Freedom of choice (Pick any dentist)• Portable• Guaranteed-renewable at the same payroll rate• Pays regardless of any other insurance you may have• No deductible• Easy to understand

Policy: LifeFeatures:

• Provides up to $200,000 of term life, whole life, or a combination of both on a very competitive basis

• Waiver of Premium Benefit• Optional Spouse & Child Riders• Optional Accidental-Death Benefit Rider

Policy: Hospital Confinement Sickness IndemnityFeatures:

• Physician Visits Benefit• Initial Hospitalization Benefit• Major Diagnostic Exams Benefit• Surgical Benefit

Policy: VisionFeatures:

• Eye Examination Benefit• Vision Correction Benefit• Specific Eye Disease/Disorder Benefit• No network restrictions

33


ENROLLMENT INFORMATION & REQUIREMENTS

Are Commission-Only employees allowed?Yes—but limited products

Are 1099 employees allowed?Yes—but limited products

Any ineligible industries?Possibly for Disability. Please contact your Word & Brown representative

RATING INFORMATION

MINIMUM EMPLOYER CONTRIBUTION

EXCLUSIONS ALLOWED BY CARRIER:Must earn $21,000 per year for Disability in CA

Minimum group size3+ for Disability

IMPORTANT: Aflac products are individual, NOTgroup; therefore, they are NOT guaranteed issue.They are “simplified” issue, meaning, employeeswill/may have to pass underwriting.

*Claims paid to policy holder, NOT to the provider.

CARVE OUTS*

PLAN ELIGIBILITY REQUIREMENTS

Group Size

Rate Guarantee

Rates vary by Industry?

COVERAGE REQUIREMENTS

Minimum 3 Participating Employees

N/A, Individual Products

Yes

None—100% Employee Paid

Carrier's Effective Date1st or 15th of the month

Premium Amount Required for 15th?N/A

Employee Waiting Periods AvailableVaries by Product

Applications must be dated within:Prior to effective date

Spouse/Domestic Partner Employees - 1 application or 2?1 application – if covered by Group Health Plan

Employee Waiver Cards Required at enrollment?Preferred

Is Over Age Dependent Verification Required?No

Are Telephone Interviews done by Underwriting?Yes—life only (large face values)

Must Brokers Carry Errors & Omissions Insurance?No—only the Aflac field force assisting the broker isrequired to have E&O

Does Carrier Offer Open Enrollment?Yes

DOCUMENTATION & PAYMENT INFORMATIONDE-6 statement required?

Payroll Records OK if no DE6?

Is a Prior Booklet required?

Is Prior Billing required?

Must submit check with initial application?

Check Made payable to:

FEESEnrollment Fee Amount

Type of Enrollment Fee

Monthly Administration Fee

BILLING OPTIONS

•Paper

•Online/Web Based

•Express Reconciliation

N/A

N/A

N/A

N/A

No—billed in arrears

Aflac

None

None

None

34


VALUE ADDED SERVICES

Aflac’s payroll deduction and Section 125 capabilities offer powerful ways to:

• Eliminate or reduce the pressure for future company-paid plans.

• Strengthen benefits packages in a tight labor market.

• Introduce choice and portability at the employee level.

• Let employees access the power of pre-tax dollars.

• Save FICA contributions.

• Communicate the value of total company benefits in real-dollar terms.

Aflac is a premier provider of insurance policies, insuring:

• Over 11,937 state governments (and government agencies) and municipalities (company statistics, December 30, 2006).

• More than 1,108 colleges (company statistics, December 30, 2006).

• Over 1,764 hospitals (December 30, 2006).

• Over 12,083 school districts (December 30, 2006).

• More than 372,000 U.S. payroll accounts (December 30, 2006).

Aflac offers superior enrollment, communications, and claims efficiencies, such as:

• Leading-Edge Technology. Our SmartApp® point-of-sale laptop enrollment system (recognized by the Smithsonian Institution)

provides instant submission of applications via electronic signature capture.

• Employee Benefits Communication System. This people-friendly program is designed to show employees the value of the

benefits their employers provide. It can communicate all benefits, including core benefits and policies sold on a voluntary

basis.

• Info One® Personalized Benefits Statements. Generally free of charge, this service illustrates the “hidden paycheck” by

calculating the total cost of employee benefits by including the employer’s share.

• Flexible Spending Accounts, including Medical Reimbursement (Section 125) and Dependent Day-Care Accounts (Section 129).

• Transit One (Section 132) transportation expense program.

• Internet Billing and Payment Capabilities. Designed for smaller accounts, this system facilitates real-time statement changes

and updates on an easy-to-use basis.

• Single-Point Billing Services. These services are for accounts with 50 or more employees.

• Corporate Alliance Programs. These include COBRA/HIPAA administration and PEO services.

• Comprehensive Call Center. This specially dedicated customer service resource handled over 9.9 million calls in 2006

(December 31, 2006).

• Outstanding Performance in Claims Service. In 2006, Aflac processed more than six million claims in the United States. Aflac

processes most claims within four days (December 31, 2006).

35


FEATURES AND BENEFITS

Benefits to Business Owners:

• Wellness Benefits that help provide an incentive for early detection, helping to mitigate claims costs; having a potentially positive

impact on medical plan experience and employee “return to work” times.

• Eliminate or reduce the pressure for future company-paid plans through “Voluntary, employee funded programs”.

• Revenue generation through FICA and Workers Compensation savings from the pre-taxing of Aflac Benefits.

• Expansion of your benefit program, at “No Cost,” increasing your retention and attraction power of quality employees.

• Ability to reduce “exposure” to Workers Compensation claims through additional programs that pay “Cash Benefits” and provide

“Disability Income” from the 1st day an employee misses work.

Benefits to Employees:

• The power to "choose" the quality of care they desire; while using added benefits to "buffer" the added costs of going outside a

managed care network in order to see a specialist or have a second opinion in time of need.

• Provides insurance products that generate cash to employees to help with out-of-pocket costs associated with illness or injury

that are not covered by traditional medical insurance plans. Allowing them the "choice" of protecting themselves, their families or

their paycheck.

• Access to affordable "Consumer Driven Health Plans" that are "owned" by the consumer, completely portable and guaranteed

renewable

Benefits to Broker:

• A client solution by providing some relief to increasing health insurance premiums by offering products that can help the

employer make decisions to increase deductibles and co-pays, position the company to pass premium expense to the

employee, and reduce an employer’s FICA taxes and potentially, Worker’s Compensation premiums.

• Relief to employees by offering products that reduce out-of-pocket expenses related to higher co-pays, deductibles and other

costs.

• Health Savings Account compatible products.

• The ability to attract and retain employer clients by offering additional products to their employees at no direct premium cost

before a competitive broker does.

• Additional credibility by working with Aflac, a rate-stable, Fortune 500 company with tremendous brand awareness and a 92%

claims satisfaction rate.

• Increased commissions and vesting opportunities with little time commitment.

• Provides the broker with an opportunity to maintain his/her competitive position with his/her employer client.

• Positions the broker to assist the employer with developing a more comprehensive benefit portfolio with no additional premium

cost to the employer.

37


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

NY

VAWVA

MD

DE

NJ

MA

ME

NH

VT

CT RI

Customer ServicePolicyholder ServicesPhone: 800-521-3535Fax: 972-510-1795

Broker ServicesRegional Support Center 888-655-5725

Commissions Please contact your Allstate representative

ClaimsAllstate Workplace Division Workplace Claim Department P.O. Box 43967 Jacksonville, FL 32203-3067 Phone: 800-348-4489 Fax: 972-510-1773

Add-ons/DeletesFax: 972-510-1786

California Coverage Area:All of California is covered.Plans are indemnity policiesand pay all benefits to theinsured unless assigned

U.S. Coverage Area:Coverage is available in shaded states. Plansare indemnity policies and pay all benefits tothe insured unless assigned

TC plan only available

38


These products are designed to cover some of the things a healthinsurance policy may not and to supplement any coveragereceived through an employer. The products are guaranteed issueat initial enrollment – meaning no medical questions are required.

Group Voluntary Term LifeThis program offers Group Voluntary Term Life for the enrollee,their spouse and dependent children. It is meant to supplementany coverage one may already have through their employer byproviding valuable life insurance coverage at an affordable cost.This coverage is ideal for those who want to protect their families,but may not need a permanent Life Policy. For convenience,premiums are payroll deducted.

Group Voluntary Term Life Insurance is designed to providecoverage for a specified time and provides the ability for anenrollee to choose a plan for themselves or the entire family. Thelump sum benefit can help offset final burial expenses or costsincurred as life events happen.

An insured or their family members may use term life insurance to:

Pay off a mortgage or other outstanding debtsProvide for childcare or educational expensesReplace income to continue the same standard of living

Additional Benefit CoverageThe Waiver of Premium and Accelerated Death Benefit are includedwith the Group Voluntary Term Life coverage. Each benefitenhances the basic coverage and can help with expensesassociated with disability or terminal illness.

Waiver of PremiumIf an insured becomes disabled prior to age 60 and the disabilitylasts for 6 months or longer, they will not be required to paypremiums for as long as the disability lasts or until they reach age65, whichever occurs first, provided the group policy remains inforce.

Accelerated Death BenefitIf an insured or spouse are diagnosed with terminal illness (definedas less than 12 months to live), this benefit pays a portion of thetotal face amount up to 50%. The remaining life insurance benefitis paid upon death of the insured.

Benefit Reduction ScheduleReduction in group insurance amounts will apply at older ages,according to the following schedule:

Insured’s Attained Age Reduction to x% of OriginalCoverage

70 65%75 50%80 35%

If the insured does not enroll during their open enrollment period,they may enroll later during the annual re-enrollment period.However, they must submit evidence of insurability with theirenrollment form.

Continuation of CoverageThe insured has the option, when no longer eligible for coverage,to continue coverage at group rates up to age 70, so long as thegroup policy remains in force.

Group Voluntary Critical IllnessGroup Voluntary Critical Illness insurance pays a lump-sum benefitupon diagnosis of a covered critical illness or condition. Havingsupplemental Critical Illness insurance can help lessen financialimpact to the wallet. It allows the insured to concentrate ongetting better, rather than spending time and energy worryingabout how to pay the bills.

The lump-sum benefit for each category of coverage helps to:

Pay for treatments not covered under medical insuranceSpend precious time with family and friendsPay for mortgage and other expenses

Traditional health insurance is valuable, but often has limits.Because medical treatments and technology are advancing daily,people are living longer with major illnesses or disease. This canbe very costly. Financial hardship can happen, due to indirectmedical expenses that health and disability insurance doesn’tcover. Group Voluntary Critical Illness insurance is a strongsupplement to current health and disability insurance coverage.

The insured may choose either a $5,000 or $10,000 basic benefitamount. Depending on the basic benefit amount selected, up to100% of the basic benefit amount will be payable in each of threebenefit categories; Coronary Artery By-Pass Surgery, Alzheimer’sDisease and Carcinoma in Situ pay 25% of the benefit amount.

Group Voluntary AccidentGroup Voluntary Accident Insurance offers the insured and theirfamily coverage against sudden accidental injuries that can occurwithout warning. It protects the insured and their family 24-hours aday, seven days a week, both on- or off-the-job.

Each pre-packaged plan doesn’t just cover the insured; if theychoose, it also covers their dependents (which can include spouseand dependent children). This valuable coverage can helpsupplement traditional medical insurance. Traditional medicalinsurance is valuable, but may limit coverage during anunexpected accidental injury.

The insured and each covered family member can be sure they willreceive:

· A lump sum benefit, in case the accident leads to death or dismemberment

· 24-7 protection for accidental injuries**· Benefit coverage that goes where you go**

Unexpected accidents can also mean unexpected out-of-pocketexpenses. Hospital stays, medical or surgical treatments,dislocations or fractures, and transportation by air or groundambulance can add up quickly and be very costly. This GroupVoluntary Accident Insurance helps offset some of these expensesso that the insured’s finances remain healthy.

**Treatment must be obtained in the U.S. or its territories.

If a covered person sustains an injury which results in a coveredloss within 90 days from the date of an accident, while coverage isin force, Allstate Workplace Division will pay the benefits as statedin the benefits provisions.

· Accidental Death· Common Carrier Accidental Death· Dismemberment· Dislocation and Fracture· Initial Hospital Confinement· Hospital Confinement· Intensive Care· Ambulance (ground and air)· Medical Expenses· Outpatient Physician’s Treatment

NOTE: This Product Overview is an agent recruitment and trainingdocument and is not intended for consumer use. The insuranceproducts discussed in this document may vary based on state ofissue and may not be available for sale in all states.

PRODUCTS OFFERED (High and Low Options)

39


DOCUMENTATION & PAYMENT INFORMATIONWage & Tax Statements required?

Payroll Records OK if no Wage & Tax Statements?






Are Commission-Only employees allowed?Yes

Are 1099 employees allowed?Yes

Any ineligible industries?Please contact your Word & Brown representative

RATING INFORMATION


EXCLUSIONS ALLOWED BY CARRIER:

Minimum group size5-200 eligible

CARVE OUTS*


Group Size

Rate Guarantee



5-200 eligible

Minimum 1 Year

No

A minimum of 5 participants are required to initiate the SBSprogram. If the total number of participants fall below 5, theemployer has 3 billing cycles (months) to bring the levels up tominimum before the plan will be terminated. Groups with over200 eligible employees will not qualify for participation

Carrier's Effective Date1st of the month

Premium Amount Required for 15th?N/A

Employee Waiting Periods AvailableEmployer Determines Eligibility

Applications must be dated within:Prior to effective date

Spouse/Domestic Partner Employees - 1 application or 2?1 application

Employee Waiver Cards Required at enrollment?Yes

Is Over Age Dependent Verification Required?No

Are Telephone Interviews done by Underwriting?Initial contact to Region, then Broker, then Employer ifnecessary.

Must Brokers Carry Errors & Omissions Insurance?Yes

Does Carrier Offer Open Enrollment?Yes




BILLING OPTIONS

Paper only

N/A

N/A

N/A

N/A

None

None

None

No—billed in arrears

Allstate Workplace Division

40


VALUE ADDED SERVICES

• 15% broker commission (1st year and renewal)

• Products are Guarantee Issue

• No participation requirements

• Products are portable as an individual component (not as a package)

• Monthly billing



What is the minimum % of employees required in NV?





Yes

N/A; 5 or more insureds

Contact your Word & Brown representativeContact your Word & Brown representative

The rates are based on SIC of company

All plan types

FEATURES AND BENEFITS

Additional Wellness Screening BenefitAllstate has enhanced the coverage by providing a Wellness Screening Benefit. A $100 benefit will be paid for one of thefollowing screening tests performed while not hospital confined:

· Bone Marrow Testing· CA15-3 (blood test for breast cancer)· CA125 (blood test for ovarian cancer)· CEA (blood test for colon cancer)· Chest X-ray· Colonoscopy· Flexible sigmoidoscopy· Hemocult stool analysis· Mammography, including breast ultrasound· Pap Smear, including Thin Prep Pap Test· PSA (blood test for prostate cancer)· Serum Protein Electrophoresis (test for myeloma)· Biopsy for skin Cancer· Stress test on bike or treadmill· Electrocardiogram· Carotid Doppler· Echocardiogram· Lipid panel (total cholesterol count)· Blood test for triglycerides

There is no limit to the number of years screening tests can be received, and the benefit is paid regardless of the result ofthe test(s). Limited to one test each calendar year for each covered person.

41


MEDICAL

Colusa

CalaverasMarin

Monterey

Sacra-mento†

Alameda

AlpineAmador

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

SanMate

SantaBarbara

Santa Clara

SantaCruz

Shasta

Sierra

Siskiyou

Solano†

Sonoma†

Stanislaus

Sut-ter

Tehama

Trinity

Tulare

Tuolumne

Ventura

Yolo†

Yuba

43


EPO/MC PPO Only Counties

All Plan Types

HMOHMO Claim Dept. Aetna P.O. Box 24019Fresno, CA 93779-4019888-702-3862

PPOPPO Claim Dept. Aetna P.O. Box 981204El Paso, TX 79998-1204888-802-3862

Claims

HMO/POS

† The HMO network is availablein select areas of Fresno,Placer, Riverside, Sacramento,San Bernardino, San Joaquin,Solano, Sonoma and YoloCounties. Contact your Word & Brown representativefor details

ME

DI

CA

L

Plan may not be available in all zip codes within county. Check withyour Word & Brown representativeto confirm if coverage is availablefor your group location.

�

Broker SupportBOR changes, renewals and group terminations 877-249-2472, Option 6Broker licensing and appointment information 866-511-2863

Email: [email protected]: 888-539-7601

Commissions 800-622-3435

Employer Support 877-249-7235Adds/Terms Fax 888-258-4528

Enrollment Department 866-910-9895(Mon-Fri., 8:00 AM – 5:00 PM EST)Fax: 866-651-3120For Group online access Eligibility you will need the Group Account number.

Payments AetnaBox #894920c/o Citibank Lock Box Operations5860 Uplander WayCulver City, CA 90230866-910-9895, Option 5

Provider Services 888-632-3862Prior Carrier Deductible Credit Fax: 859-455-8650

(include new Aetna ID number and a copy of ID card and/or SSN and date of b irth)

Member Support 888-702-3862 (HMO)888-802-3862 (PPO/Indemnity)

Bilingual Support See member support numbers aboveCal COBRA Department 888-595-1542

Fax: 866-651-3120

HMOAetna HMOAetna HMO Value NetworkAetna HMO HRA and HMO DeductibleNetwork

EPOMC Plans: Managed Choice®

PPOPPO Plans: Open Choice®

LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

PRODUCTS OFFERED

OPTIONAL BENEFITS

GROUP SIZE

PROVIDER INFORMATION

HMO/EPO PPO POS

44

CONSUMER DIRECTED HEALTHCARE

HSA-CompatiblePPO

HRA-CompatiblePPO


Is Workers' Comp required oncorporate officers, partnersand sole proprietors?No

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

Is there a premium adjustmentfor 24 hour coverage?No

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

Can family members eachchoose a PCP from a differentIPA/Medical Group?

Does carrier allow an OB/GYNto be Primary Care Physician?

Self-referral available?

Express referral available?

●

Available

Available

Included

Please refer to Infertility Section on page 47

Discount Included

Discount Included

2-50

Standalone life available 26+.

Aetna

Aetna

AetnaHMOPlans

Aetna HMO Plans

HMO PPO/EPOAetna Indemnity

Indemnity

●Aetna EPO 1

●Aetna MC Plans

●Aetna PPO Plans

●Aetna MC HDHP

●Aetna Indemnity***

●

AetnaEPO

●

●

●

●

●

AetnaMC

Plans

●

●

●

●

●

●

AetnaPPOPlans

●

●

●

●

●Aetna Value Network $10/$20**Aetna Value Network $30/$40**

● ● ●

● ● ●

●

MCHDHP

●

●

●

●

●

AetnaIndem.

●

●

●

●

N/A

HMO $10HMO $15HMO $20HMO $30HMO $40

HMO Deductible $1,000Aetna HMO HRA $750 $15/$30Aetna HMO HRA $1500 $25/$50Aetna Value Network HMO $10Aetna Value Network HMO $20Aetna Value Network HMO $30Aetna Value Network HMO $40

MC HDHP HSA $2,300 80/50MC HDHP HSA $3,000 100/50MC HDHP HSA $3,300 80/50

DUAL OPTION (MIX AND MATCH)

Boxes containing a “●” indicate that these coordinate plans offered by thiscarrier can be written together to create a dual option package. Blankboxes indicate which plans cannot be written together.

Aetna

Aetna

No—see self-referral information above

HMO: Yes—OB/GYN well woman exams (including PAP smear),gynecological-related problems, follow-up care & obstetrical carePPO: YesEPO: Yes

SELECTION

SPECIALIST REFERRALS

NETWORKS

HMO: Anytime. Change must berequested by the 15th of the month tobe effective the 1st of the following monthEPO, PPO & Indemnity: No PCP selection is required

Yes

Yes—if OB/GYN is listed as a PCP

For 2+ groups when sold withmedical. No excluded industrieson dental

●

ALTERNATIVE DISCIPLINES

●

We offer chiro with some of our medical plans andalongside our discount program, this benefit isunlimited with the discount program.

MC HDHP HRA $3,000 80/50

MC $250 90/70MC $250 80/60MC $500 80/60

MC $750 80/50/50MC $1,000 80/50/50

MC $1,000 70/50 MC $2,000 80/50/50

MC $2,500 75/50MC Basic

MC $10,000 100/50PPO $500 90/70PPO $750 80/60

Out of State PPO $250Out of State PPO $500Out of State PPO $1000

MC HDHPAetna EPO 80

Aetna's multi option program is called Pick-A-Plan. Employers of groups with 2+ enrolling employees (excludingCal-COBRA/COBRA) can select up to 32 different plans at the time of initial enrollment. All plans selected at initialenrollment will be available to future new hires even if no one enrolled at the initial effective date.

**Aetna’s Value Network may be included in a Pick-A-Plan package alongside all HMO plans.

***Aetna’s Indemnity plan is only available if MC and PPO networks do not exist in areas within California.

●

●

●

●

●

●

24 HOUR COVERAGE


AFTERINITIAL ISSUE

ENROLLMENT GROUP SIZE

Employees

Dependents

Employees

Dependents

EXCLUSIONS ALLOWED BY CARRI-ER:Hourly/Salary?

Management/Non-management?

Union/Non-union?

Minimum group size

Does carrier underwrite and rate

* 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:



PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

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 PPO or indemnity plan?

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

SPECIAL CONSIDERATIONS

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EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Yes—subject to Aetna Underwriting approval †

Management/Non-management?Yes—subject to Aetna Underwriting approval †

Union/Non-union?Yes—will be considered guarantee-issue when proof ofcoverage is provided on the union employees. Aetna musthave a minimum of 8 subscribers enroll. Eligibility forunion/non-union carve-outs is based on the number of non-union employees.

Minimum group size8 enrolled with Aetna who reside within Aetna’s California Network Service Area.

Does carrier underwrite and rate carve out groups accordingto AB1672 guidelines?No—carve-outs are not subject to AB 1672 guarantee issue requirements and may be denied by Aetna.


2-50

50%

N/A

N/A

1* 1*50 N/A

2-50 Yes—standard participation of 75% must be met in order for a group to qualify for coverage.Employees waiving due to coverage throughspouse will NOT be considered eligible incalculating participation for a group sold alongside another carrier

Aetna

Aetna

Aetna

Aetna


◆◆ 100% 100%

N/A N/A

2-3 4-50

◆◆ 100% 75%

N/A N/A

Pick-A-Plan 2-50

Two Options:1) 50% of the employee rate

for plan employee selects;2) Defined contribution of at

least $80 or the actual costof the plans picked,whichever is less

† Employer must provide all employee class definitions in writingon company letterhead prior to approval.

Groups of 25-50 enrolling employees are no longer required to submitany business structure paperwork (Articles of Incorporation, Statementof Information, Statement by Domestic Stock Corporation, Schedule K-1’s, etc.) with the initial new group submissions. In addition to theEmployer and Employee applications, we will simply require the DE-6and an Aetna Proof of Employer Eligibility Form if the officers are notlisted on the DE-6.

Groups will go through the Aetna re-verification annually. Aetna sendsout the documentation 6 months prior to the effective date.

Dependents who reside separately from the employee and are not in anapproved Aetna service area will be enrolled on the subscriber's HMOplan and will need to access care via the selected Primary Care Physicianin the subscriber's/family's HMO service area (except for urgent andemergency care). Any dependent that is currently enrolled in the out-of-area dependent Aetna PPO plan will not be impacted by this change solong as they remain eligible for coverage.

◆ Those covered by another plan are NOT considered eligible in calculating participation

◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan, Medicare or Medicaid

Min. # of employeesMax. # of employees

*AB 1672 group of 2 with one valid waiver due to other groupcoverage, Medicare or Medicaid

2-50 Yes—Aetna will accept the greater of 50% eligibleand a minimum of eight enrolled when writingalongside another carrier's HMO plan. Employeeswaiving due to coverage through spouse will NOTbe considered eligible in calculating participationfor a group sold alongside another carrier.(Standard participation applies alongside another carrier's POS, EPO or PPO plans.)

COVERAGE RESTRICTIONSAre Commission-Only employees allowed?Yes—must be full-time employee, have an employer/employeerelationship and have workers' comp coverage. Need to submitDE-6 for proof

Are 1099 employees allowed?Yes—if employer submits Aetna’s 1099 Contractor VerificationForm along with the individual’s last year’s 1099-Misc. tax formsand tax returns. 1099 employees must have been covered underprior small group health plan in order to be eligible for coveragewith Aetna. No more than 25% of the group may be 1099employees.

Are employees covered if traveling out of USA?Emergency services. Other services are paid at the non-networkbenefit level.

Is coverage available for out-of-state employees?Yes—employees who reside out-of-state will be offeredCalifornia plans and rates. Product availability is based onnetwork availability: • Out-of-state employees who reside in an area with an MC

network must enroll in an MC plan; • Out-of-state employees who reside in an area with a PPO

network must enroll in a California PPO plan;• Out-of-state employees who reside in an Indemnity-only

network must enroll in a California Indemnity plan;• HMO & EPO plans are not available outside California

Max. % of employees residing out-of-state allowedAetna does not have a maximum out-of-state percentage.However, if more than 49% of employees reside outside of CA,group will not be guarantee issue


MEDICAL UNDERWRITING REQUIREMENTS

Current Employees

TimelyAdd-ons

RAF Increments (2-50 lives) 5-50: Determined byunderwriting

Composite Rates Available on all plans for smallgroup with enrolling CA employees.Maximum of 4 plans may be offeredwhen taking composite rates, andmust have 1 member enrolled in theplan for it to be offered to new hires

Rate Guarantee†† 12 Months

Apply Trend Factor? No

Use Employee Zips? No—groups rated based onemployer zip code. (Employee zipcodes must also be provided.)


Carrier's Effective Date

Premium Amount Required for 15th?

Employee Waiting Periods Available

Applications must be dated within:

Spouse/Domestic Partner Employees - 1 application or 2?

Employee Waiver Cards Required at enrollment?

Is Over Age Dependent Verification Required?

Are Telephone Interviews done by Underwriting?

Must Brokers Carry Errors & Omissions Insurance?

Does Carrier Offer Open Enrollment?

DOCUMENTATION & PAYMENT INFORMATIONDE-6 statement required?









DEDUCTIBLE CREDITPrior carrier deductible credit given?

4th quarter deductiblecarry-over credit given?

GROUP SIZE

RATING INFORMATION

46

Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989†† 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

Current Employees

TimelyAdd-ons

Yes†

Yes—minimum 2 weeks*

No

Yes

Yes

Aetna, Inc.

N/A

N/A

N/A

Yes

No

Yes

No

No

No

Yes

No

No

No

No

No

No

No

No

17 Medical 5 MedicalQuestions on Questions on

Employee App Employee App

Non NonMedical Medical

1st or 15th of the month

N/A

Min: 1st of the month following date of hireMax: 6 months/180 days

60 days & prior to requested effective date

Either 1 or 2 applications

Yes—plus copy of current carrier ID card

Yes

No

Yes

Yes—30 days before renewal anniversary

Aetna

Aetna

GROUP SIZE

HMO, HMO HRA, M/C, PPO & Indemnity

* Payroll records must include the number of hours worked for each employee. If no DE-6, group must also submit copy of their business license and tax ID number. Groupmust be in business a minimum of 50% of prior quarter in order to be guaranteed issue.

No

2-10 11-50

† See Special Considerations on page 45 for important details regarding 5+groups with owners, partners or corporate officers not on DE-6.

Infertility

Adult Physical Child Physical Annual OB/GYNPLAN TYPE Exam Exam/Immunizations Visit/Pap Smear Mammography


SPECIAL CONCERNS*

Hearing treatment

Are Hearing Aids Covered?

Speech therapy

PREVENTIVE BENEFITS*

PRESCRIPTIONS

* Information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.

FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?

Are non-formulary drugs available?

MAIL ORDER - 90 DAY SUPPLY

Are oral contraceptives covered?

* Unless otherwise noted, information shown in this section reflects in-network benefits. For Triple Option plans, the most managed plans are shown.

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.

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MAIL ORDER


Contact your Word & Brown representative

No—we will honor ‘dispense as written’

Yes

Yes

Yes—higher non-formulary copay applies

HMO & PPO plans: 2X retail copay - 31 day up to 90 day

supply available

Yes

* Information shown in this section reflects in-network benefits.

Aetna

Aetna

Aetna

HMO, EPO & all PPOsexcept MC Basic

100% after copay 1 100% after copay 1 100% after copay 2 100% after copay 2

M/C, PPO & Indemnity

Limited to every 12 months

MC Basic & Indemnity Coinsurance applies 1 Coinsurance applies 1 Coinsurance applies 2 Coinsurance applies 2

GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand name drug?

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

No prescription deductibles on any plan

1Age & frequency schedules apply2Frequency schedules apply

All plans: Coverage only for the diagnosis andtreatment of the underlying medicalcondition. Member cost sharing isbased on the type of service performedand place where it is rendered. (SeeCertificate Book for details). Nocoverage for artificial insemination, IVF,ZIFT, ICSI & other related services

HMO $30, HMO $40MC $750 80/50/50, MC $1000 80/50/50,MC $2000 80/50/50:

GIFT is covered on these plans onlywith a lifetime maximum of $2000 permember. IVF and injectable medications areexcluded


Call your Word & Brown representative

See plan benefits todetermine coverage




DIABETIC BENEFITS

These services may change at any time without notice. Please contact your Word & Brown representative for specific inquiries on listed services

48

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

Insulin

Needles & Syringes

Glucose Monitor

Chem-Strips and/or Testing Agents

Insulin Pump

Insulin Pump Supplies

SELF-INJECTABLE DRUG BENEFITS

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

Prescription Drug Benefitor Medical Benefit?

Is pre-authorizationrequired?

Must self-injectables(other than insulin)

be purchased via thecarrier-contracted

mail order Rx vendor?

Aetna

Aetna

Aetna

Prescription Drug Benefit


Medical/Durable Medical Equipment Benefit




MedicalBenefit

Generally under the 4th tierPrescription Drug Benefit

Generally under the 4th tierPrescription Drug Benefit

Depends on drug*

Depends on drug*

Depends on drug*

Typically through AetnaSpecialty Pharmacy



* Check Aetna's Rx formulary at www.aetna.com/formulary

HMO plans:

EPO & MC plans:

PPO & Indemnity plans:

Access Baja HMO plans can meet the needs of Californiaemployers whose workers seek coverage in BajaCalifornia, Mexico.

Members must live or work in the municipality of Tijuanaor Mexicali, or the area in California, U.S., generallywithin a 50-mile radius from the border crossing points atSan Ysidro and Calexico. For small groups, the AccessBaja HMO plans must be offered alongside another BlueShield plan(s).

Colusa

CalaverasMarin

Monterey

Sacra-mento

Alameda

AlpineAmador

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

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Member Support 800-424-6521 (HMO)Customer Service 800-535-8000 (PPO) Bilingual Support 800-248-5451Claims Fax 209-367-2880Pre-Authorization Dept. 800-821-1315Cal-COBRA Dept. 800-228-9476

Fax 916-350-7480Sm. Group Cancellations/Reinstatements Fax 209-367-6369Group Service 800-325-5166

Broker Licensing Dept. Fax (209) 371-5830Email: [email protected]

Commissions 800-559-5905Adds/Terms Fax 209-367-6475

Pharmacy Services Dept. 800-535-9481

Blue ShieldP.O. Box 272540Chico, CA 95927-2540800-200-3242

PPO Only Counties

HMO & PPO Counties�

AdministratorBlue Shield New Business3021 Reynolds Ranch Pkwy.Lodi, CA 95240

proud participant in:

HMO/POS

Small GroupPremium PaymentsBlue Shield of California File 55331 Los Angeles, CA 90074-5331

Billing800-325-5166, Option 3

Claims

Plan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.

50




Available

Available

Available

Rider Available*

Available

Available

Discount †

2-50

HMO/EPOBlue Shield HMOLocal Access+ HMO Network* (*Available toemployers in portions of Los Angeles, SanDiego, Orange, San Bernardino and Riverside)

PPOBlue Shield PPOBlue Shield Life Network (Active Choice Plans, Shield Spectrum PPO Plan500 Value, Plan 500 Standard, Shield SpectrumPPO Plan 750 Value, Shield Spectrum PPO Plan1000 Value, Shield Spectrum PPO Plan 1500Value, Shield Spectrum PPO Plan 2000 Value,Shield Spectrum PPO 3000, Shield Savings Plan1800/3600, Shield Savings Plan 2000/4000,Shield Savings Plan 2500/4500, Shield SavingsPlan 3000/6000 & Shield Savings Plan 4800)

POSBlue Shield PPO & Blue Shield HMO

†Discount provided throughMylifepathSM program

PRODUCTS OFFERED

MIX AND MATCH

OPTIONAL BENEFITS

GROUP SIZE

PROVIDER INFORMATIONHMO/EPO

Blue Shield of CA

Blue Shield of CA

Blue Shieldof CA

LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

Active Choice Plan 500 SG Active Choice Plan 750 SG

Shield Spectrum PPO Plan ZeroDeductible

Shield Spectrum PPO Plan 500 ValueShield Spectrum PPO Plan 750 Value

Shield Spectrum PPO Plan 250 Premier Shield Spectrum PPO Plan 250 Standard Shield Spectrum PPO Plan 500 Premier

Shield Spectrum PPO Plan 500 StandardShield Spectrum PPO Plan 1000

Shield Spectrum PPO Plan 1000 ValueShield Spectrum PPO Plan 1500 ValueShield Spectrum PPO Plan 2000 Value

Shield Spectrum PPO Plan 3000 †

Added AdvantagePOS

Shield Savings Plan 1800/3600†

Shield Savings Plan 2250/4500†

Shield Savings Plan 2000/4000Shield Savings Plan 2500

Shield Savings Plan 3000/6000Shield Savings Plan 4800

Shield Savings Plan 1800/3600Shield Savings Plan 2250/4500

Shield Spectrum PPO Plan 3000

Access+ HMO Plan 5Access+ HMO Plan 10Access+ HMO Plan 15Access+ HMO Plan 20

Access+ HMO Plan 20 ValueLocal Access+ HMO Plan 20 Value

Access+ HMO Plan 25Access+ HMO Plan 30

Local Access+ HMO Plan 30Access+ HMO Plan 40

Access Baja HMO Plan 5Access Baja HMO Plan 10

Dual Option (HMO & PPO or HMO & POS) available 2-50 lives. PlanSelect: Groups of 2-50 enrolled employees can pick ANY combination of plans or all 28 small group plans: 8 HMO, 12 PPO, 1 POS, 2 Active Choice, and 5 HSA-eligible plans.

PlanSelect is available to groups 2-50 with any combination from 2-28 different health plan choices.

Suite Deal program: Employers with 2-50 enrolled employees can choose any of the following:

Access+ HMO® Plan 20 Value Shield Spectrum PPO Plan 1500 ValueAccess+ HMO Plan 30 Shield Spectrum PPO Plan 2000 ValueShield Spectrum PPO Plan 500 Standard Shield Savings Plan 2000/4000Shield Spectrum PPOSM Plan 500 Value Shield Savings Plan 3000/6000Shield Spectrum PPO Plan 1000 Value

Employer may offer the Suite Deal program with the Local Access HMO plans or the Standard HMOplans - but not both. All plans in the Suite Deal must be offered—however, enrollment in all plans is notrequired. Employer must contribute either 1) a defined contribution consisting of a minimum $100 peremployee (or the cost of the total employee rate, whichever is less), or 2) a minimum of 50% of the totalemployee rates.

Employees may choose from the plans selected by their employer. Employer must contribute aminimum of $100 per enrolled employee or 50% of total employee rates.

Access Baja can be offered in addition to PlanSelect and is not included in a PlanSelect package as oneof the choices.

Local Access+ is not available with PlanSelect.


HSA-Compatible PPO HRA-Compatible PPO




HMO & POS: YesPPO: N/A

Yes—if listed as a PCP in the directory

HMO: OB/GYN visits—yes; Other services: if Access + provider—yes All services: specialist must be in same med.group/IPA as PCPPOS: Yes—PPO and non-PPO portions onlyPPO: Yes

No—see self-referral information above

Blue Shield of CA

Participants may change anytime bycontacting Member Services. Changewill be effective on the 1st day of month following notice of approval

SELECTION

NETWORKS


† Only these two HSA-compatible plans plus the non-HSA compatible Shield Spectrum PPO 3000 plan can be used in conjunction with a self-funding arrangement


Is Workers' Comp required oncorporate officers, partnersand sole proprietors?No

Is on-the-job covered for corporate officers, partnersand sole proprietors?YesIs there a premium adjustmentfor 24 hour coverage?Yes—if group does not have Workers’Comp

24 HOUR COVERAGE

POSPPO


Employees

Dependents

Employees

Dependents


Employees

For Dependents

% of Total Cost:



PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE


WRAP* REQUIREMENTS




51

COVERAGE RESTRICTIONS

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. % of employees residing out-of-state allowed

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2-50

2-50

50%

N/A

N/A

1* 1*

50 N/A

2-50 No


1) These plans have an Annual Brand Rx Deductible:$150 Annual Brand Rx Deductible*

Access+ HMO 20, Access+ HMO 20 Value, Local Access+ HMO Plan 20 Value,

Access+ HMO Plan 30, Local Access+ HMO Plan 30,

PPO Plan 500 Premier and Added Advantage POS $250 Annual Brand Rx Deductible*

Access+ HMO Plan 25,Access+ HMO Plan 40,

PPO Plan 500 Standard, PPO Plan 1000, PPO Plan 500 Value and Active Choice 750

PPO Plan 750 Value$500 Annual Brand Rx Deductible*

PPO Plan 3000 and Active Choice 500 —2) Blue Shield no longer requires the following paperwork for guaranteed

issue groups of 25 to 50 enrolled employees: Articles of Incorporation,Schedule K-1, Statement by Domestic Stock Corporation, and/or Statementof Information. The group’s DE6 is required and, if the company offi-cers/owners are not listed on the form, the group must also submit a SoleProprietor, Partner or Corporation Officer Statement (form C-15293) foreach officer/owner.

3) Upon enrollment in Suite Deal or Dual Choice, the employer must chooseto either offer Local Access+ HMO or Access+ HMO plan(s). They cannotbe offered together.

Blue Shield of CA

Blue Shield of CA

Blue Shield

EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?


Union/Non-union?

Minimum group size

Does carrier underwrite and rate carve out groups according to AB1672 guidelines?

Yes—if total group size is 50 or less. Health statements are requiredregardless of group size. Participation: 75% of all eligible employeeswith a minimum of 8. Blue Shield must be the only carrier

Yes—see requirements above

Yes—if total group size is 50 or less.UNION EMPLOYEES: When a small group employer, in compliancewith a collective bargaining agreement, is purchasing healthcarebenefits for his union employees, those union employees will beconsidered eligible by Blue ShieldUNION TRUST PLANS: When a small group employer is contributingto a labor fund, in compliance with a collective bargaining agreement,for the purchase of healthcare benefits, that employer's unionemployees will be considered ineligible by Blue Shield. Copies of theunion’s statement of ERISA rights will be required.FOR BOTH: If total employees (union plus non-union) is 50 or less,group will be guarantee issue.Legal documentation verifying employer's method of compliance withthe collective bargaining agreement is required.

8 (except for the union situation outlined above witha minimum group of 2)

No—therefore a carve out group could get a final RAF higher than1.10 or be declined (only exceptions are the union situations outlinedabove)

◆◆ 75%

◆◆ N/A

◆◆ 100%

◆◆ N/A

*AB 1672 group of 2 with one valid waiver due to other group coverage

*This separate per member Rx deductiblealso applies to home self-administeredinjectable drugs


◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan

AFTERINITIAL ISSUE


Min. # of employees

Max. # of employees2-50 Blue Shield Single, Option, Dual Option or

Suite Deal: Yes—a minimum of 5 or 50% ofthe total active enrolled employees(whichever is greater) must enroll with BlueShield.

Blue Shield PlanSelect Package: Yes—aminimum of 5 or 75% of the total activeenrolled employees (whichever is greater)must enroll with Blue Shield

†Signed refusal required for all Kaiser enrollees.

Yes—commission-only employees are eligible if they are on the DE-6

No

Yes

Yes*—Blue Card program available. Access+ HMO and POS plans are not designed to provide coverage for employees who reside outside of California. Employers with employees who reside or work for over six months outside of California should consider a PPO plan*Except employees living in Hawaii

For guaranteed issue, a maximum of 49% out-of-state employees allowed. When there are not at least 51% of the employees in CA, the out-of-state employees are not eligible for coverage and the CA employees can only be written on a non-guaranteed issue basis

2-50 Suite Deal(See Mix & Match Section - page 50)

◆◆ 100%

◆◆ N/A

◆◆ 65%

◆◆ N/A

A minimum of $100 peremployee or a minimum of 50%

of the total employee rates

N/A

N/A

2-50 Defined Contribution



Current Employees

TimelyAdd-ons

Group Size

Composite Rates

Rate Guarantee*

Apply Trend Factor?

Use Employee Zips?












DOCUMENTATION & PAYMENT INFORMATION

DE-6 statement required?




Must submit check with

initial application?


FEES

Enrollment Fee Amount



DEDUCTIBLE CREDITPrior carrier deductible credit give

GROUP SIZE

RATING INFORMATION

52

Instant quotes online: www.wordandbrown.comQuotes in 24 hours: (800) 869-6989

†† 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 ConditionsYears in Business# of PregnanciesVirgin GroupType of IndustryPercent of OwnersGroup Size% of COBRA Insureds% of Family RelatedParticipationPlan(s) Requested24 HR Coverage Req'dEmployer ContributionBankruptcy Gender Mix

Current Employees

TimelyAdd-ons

GROUP SIZE

RATING INFORMATION

.025

2-50 Not Available

12 Months

No

No

1st of the month unless replacing

Submit one month's premium

Min: 1 Max: 180 (1st of month following)*

45 days

Yes

Yes

No

Yes

Yes—30 days prior to renewal date

Yes*


No

Yes

Yes

Blue Shield

None

N/A

None

2-14 15-50

Full Employer Medical Questionnaire

Non NonMedical Medical

Blue Shield of CA

Blue Shield of CA

HMO & Active Choice PPO: N/APPO & POS: Yes †

Prior carrier deductible credit given?

4th quarter deductiblecarry-over credit given? No

†This does NOT include credit for the Rx Deductible

*Employer may elect 2 different waiting periodsbased on class of employees

RAF Increments (2-50 lives)

Composite Rates

Rate Guarantee††

Apply Trend Factor?

Use Employee Zips?

YesNo*YesNoYes †

NoYesYesNoYesYesYesYes NoNo

* If group meets guarantee issue criteria, then years in business is not takeninto consideration. However, for a new group that does not meet guaranteeissue criteria, years in business is a determining factor for group eligibility.

† 15+ groups without individual health statements in these industries willreceive a 10 point load: medical services (doctors, hospitals, urgent centers),convalescent hospitals, lawyers, insurance agents, municipalities, schooldistricts, car dealers, religious organizations and construction.

Either 1 or 2 applications. Refusal required if electing to enroll as dependentbut does not count against participation. When husband and wife areenrolling separately under the same group a waiver form is required

* DE-6 must be unaltered. If any alterations special requirements apply. Call your Word & Brown representative for details.

Access+ HMO 20 Value, 25, 30 & 40,Local Access+ HMO 20 Value and 30: No—unless prior authorization is obtained from Blue

ShieldPPO Plan Zero Deductible, PPO Plan 250 Premier, PPO Plan 250 Standard, PPO Plan 500 Premier, PPO Plan 500 Standard, and PPO Plan 1000: Yes - $50 non-formulary copay appliesHMO Plan 5, HMO Plan 10, HMO Plan 15, & HMO Plan 20: Yes - $45 non-formulary copay appliesPPO 500 Value, Active Choice 500, Active Choice 750, & PP0 3000: Yes - $50 non-formulary copay applies (or 50% of

contracted rate, whichever is greater)Shield Savings Plans 2250/4500, Yes, $50 non-formulary copay applies (or 50% of & 2500: contracted rate, whichever is greater). Medical

deductible appliesShield Savings Plans 1800/3600,2000/4000, 3000/6000 & 4800 (HSA): Yes - $0 copay Medical deductible applies

HMO Plan 5 & HMO Plan 10: $20 generic/$50 form. brand/$90 non-form. brandHMO Plan 15 & HMO Plan 20: $30 generic/$60 form brand/$90 non-form. brand PPO Plan 500 Value, PPO Plan 3000,Active Choice 500 & 750*: $30 generic/$60 Brand-name drug or 30% of Blue

Shield Life contracted rate, whichever is greater/$100non-form. brand or 50% of Blue Shield Lifecontracted rate whichever is greater

PPO Plan 750 Value, Plan 1000 Value & PPO Plan 1500 Value: $30 Generic drug, $60 Brand-name drug or (30% of

Blue Shield Life contracted rate, whichever isgreater.) (see special considerations on page 51)

PPO Plan 2000 Value: Generic $30, Brand is not covered HMO 20 Value, HMO Plan 25, Local Access+ HMO 20 Value and 30,HMO Plan 30 & HMO Plan 40: $30 generic/$60 formulary brand

Added Advantage POS Plan: $30 generic/$60 formulary brandPPO Plan Zero Deductible & PPO Plan 250 Premier: $20 generic/$50 form. brand/$100 non form. brand.PPO Plan 250 Standard, PPO Plan 500 Premier, PPO Plan 500 Standard & PPO Plan 1000: $20 generic/$60 form. brand/$100 non form. brand.Shield Savings Plans (HSA): Savings Plans 2250/4500, & 2500: Medical deduct. applies first then, $20

generic/$60 Brand-name drug or 30% of Blue Shield contracted ratewhichever is greater/$100 non-form. Brand or 50% of Blue Shieldcontracted rate whichever is greater.

Shield Savings Plans 1800/3600, 2000/4000, 3000/6000 & 4800: $0 copay after medical deductible.



GENERIC VS. BRAND NAMEIf generic available, and doctor has notindicated “dispense as written,” willmember receive a generic equivalent ratherthan a brand name drug?

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

Yes—or member must pay generic copay plus differencebetween cost of generic and brand name drug

SPECIAL CONCERNS*

PRESCRIPTIONS



53

Hearing treatment

Are Hearing Aids covered?

Speech therapy


Access + HMO Covered at 100% Covered at 100% Covered at 100% Covered at 100%PPO-Active Choice Covered under Category 1, Covered under Category 1, Covered under Category 1, Covered under Category 1,

First Dollar Services coverage† First Dollar Services coverage† First Dollar Services coverage† First Dollar Services coverage†

PPO (except Active Choice) 100% after 100% after 100% after 100% afteroffice visit copay office visit copay office visit copay office visit copay(in-network only) (in-network only) (in-network only) (in-network only)

POS Covered at 100% (level 1 only) Covered at 100% (level 1 only) Covered at 100% (level 1 only) Covered at 100% (level 1 only)

HMO & POS: Hearing screening exams by PCP covered at 100% up to age 18

PPO: Covers ear screenings to determine the need for audiograms for dependent children through age 18 only


Blue Shield of CA

Blue Shield of CA

† Member is responsible for all charges above the individual or family First Dollar Services amount until member's Maximum Calendar Year Copayment has been reached

Are oral contraceptives covered?Yes—for all plans

Yes

InfertilityHMO & POS: 50% for diagnosis & treatment of cause of

infertility. Rider available covering limited ZIFT, GIFT, IVF, etc.—call representative for details

PPO: Not covered unless rider is added - contact representative or see brochure for more information

Covered as outlined in the Schedule of Benefits and Evidenceof Coverage.

* Unless otherwise noted, information shown in this sectionreflects in-network benefits. For Triple Option plans, themost managed plans are shown.


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Blue Shield of CA

All Blue Shield plans have a waiver of deductible for preventive care

No

An annual prescription drug limitation applies to the followingplans:PPO Plan 1000 Value: Subject to $1,000 maximum on brandname drugs, per person, per calendar year. PPO Plan 1500 Value: Subject to $500 maximum on brandname drugs, per person, per calendar year.

*See Special Consideration #1 on page 51 for important information on Annual Brand Rx Deductible

FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?Yes—for all plans


DIABETIC BENEFITS


54

DISCOUNTS, AWARDS & OTHER VALUE-ADDED BENEFITS









Blue Shield of CA

Blue Shield of CA

Prescription Drug Benefit †—if plan has an annual brand Rx

deductible, this deductible also applies to home self-administered injectables

Prescription Drug Benefit †—(in-network only) If plan has an

annual brand Rx deductible, thisdeductible also applies to home

self-administered injectables

Some medications and/ordosages may require

prior authorization


prior authorization

Yes*—Caremark 800-237-2767& Curascript

888-773-7376, option 3


888-773-7376, option 3

HMO plans:**

PPO plans:

Covered under the medical benefit -

Medical Deductible applies


prior authorization


888-773-7376, option 3

HSA plans:

† Home self-administered Injectables require prior authorization and are listed in the Blue Shield of California Prescription DrugFormulary. Please note that self-administered injectable copays vary from those for other prescription drugs.

* Imitrex and Lovenox will continue to be available from any Blue Shield participating pharmacy with prior authorization.

Blue Shield of CA



Diabetes Care Benefit*




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

Insulin

Needles & Syringes

Glucose Monitor


Insulin Pump


*Subject to medical deductible if plan has one, and coinsurance. Does not have $2000 annual maximum of Durable Medical Equipment

55

Colusa

CalaverasMarin

Monterey

Sacra-mento

Alameda

AlpineAmador

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 �PPO Only Counties

HMO & PPO Counties


CaliforniaChoice®

Customer Service Center 800-558-8003Blue Shield of California

HMO (English) 800-424-6521HMO (Spanish) 800-248-5451PPO 800-535-8000

Health Net 800-361-3366Kaiser Permanente

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

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

To contact by mail, or for payment submission:CaliforniaChoice® Benefit Administrators721 South Parker, Suite 200Orange, CA 92868

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

Broker of Record Changes Fax 714-972-7368

Adds/Terms Fax 714-558-8000

Billing Questions 800-558-8003

Member Support

The following HMOs have an “Excellent” rating from the NCQA

for their commercial products:

Blue Shield of CA (HMO/POS)Health Net (HMO/POS)

Kaiser Permanente (HMO)Western Health Advantage


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Refer to summary on pages 60-61



Maximum Choice For EmployeesEach employee's health care needs are different. The CaliforniaChoice®

program provides employees the maximum choice in meeting thoseneeds with these health plans—all within one program:

HMO

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

2-50

Networks vary according toHealth Care Service Plan (HCSP)

No

No

Yes

PLEASE NOTE: Not all healthplans are available in all areas

PRODUCTS OFFERED

MULTI OPTION (MIX AND MATCH)

OPTIONAL BENEFITS

GROUP SIZE


Group Size Plans Available

5-9 medically enrolledemployees

All HMO and HMO Value Plans and CalChoice® PPO 1000,CalChoice® PPO 2400, CalChoice® HSA 1500, CalChoice® HSA

2400 & Active Choice 500

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.

10+ medically enrolledemployees

All HMO and HMO Value Plans and CalChoice® PPO 750,CalChoice® PPO 1000, CalChoice® PPO 2400, CalChoice® HSA

1500, CalChoice® HSA 2400 & Active Choice 500

CaliforniaChoice® PPO Guidelines

For Salud HMO ymas, only Saludnetwork optional

benefits are shownhere. SIMNSA

network benefitsvary—call your Word & Brown representative

for details

CaliforniaChoice®

CaliforniaChoice®

CaliforniaChoice®

LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

Blue Shield of California PPOBlue Shield of California HMOHealth Net HMO

Elect Open Access (from Health Net)Salud HMO y mas

Kaiser Permanente HMOSharp Health Plan HMOWestern Health Advantage HMO

24 HOUR COVERAGE



Express referral available?Varies by Health Care Service Plan (See summary on pages 60-61)

Varies by Health Care Service Plan (See summary on pages 60-61)


HSA-Compatible PPO

HRA-CompatiblePPO

MRP-CompatiblePPO

CalChoice® HSA 1500 †*CalChoice® HSA 2400 †*

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

Salud HMO y mas

PPOCalChoice® PPO 750 †

CalChoice® PPO 1000 †

CalChoice® PPO 2400 †

CaliforniaChoice®

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 adjustmentfor 24 hour coverage?

SELECTION

NETWORKS



Active ChoiceSM 500 †

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

2-4 medically enrolledemployees

All HMO and HMO Value Plans and CalChoice® PPO 1000, CalChoice® PPO 2400, CalChoice® HSA 1500

& CalChoice® HSA 2400

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

Employees

Dependents

Employees

Dependents

57


Are Commission employees allowed?





*100%

N/A N/A

2-2 3-50

Yes—if on DE-6 and showing at least minimum wages and withholdings

No

Only for emergency benefits

Yes*— CalChoice ® PPO 750, CalChoice ®1000, CalChoice ® 2400, Active Choice SM 500, CalChoice ® HSA 1500** and CalChoice ® HSA 2400**

* Except for employees in Hawaii** HSA-Qualified High Deductible Health Plan

49% (Main office must be located in California)

2-50

50% of lowest cost plan

N/A

N/A

2 250* N/A

2-50 No

2-50 No

*100% ◆70%

N/A N/A

◆ 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


Employees

For Dependents

% of Total Cost:



PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE


WRAP* REQUIREMENTS





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

†

CaliforniaChoice®

CaliforniaChoice®

CaliforniaChoice®

CaliforniaChoice®

AFTERINITIAL 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?

* 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) M

ED

IC

AL


Current Employees

TimelyAdd-ons




















FEES



Monthly Billing Fee



GROUP SIZE


RATING INFORMATION

58





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 only

N/A

Min: 30 Max: 365

60 days

Use either 1 or 2 applications

Yes

Yes

Yes

Yes—60 days prior to anniversary

Yes

Call representative

Yes*

Yes*

Yes

C.C.B.A. (California ChoiceBenefit Admin.)

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 .90. See quote for details.

N/A

12 Months

No

HMO: YesPPO: Yes

2-14 15-50

Employee Master AppMedical (Employer

Questionnaire Questions)

Non Non Medical Medical

CaliforniaChoice®

CaliforniaChoice®

(if enrolling separately, 2 applications required)

HMO: N/APPO: Yes*

No


Composite Rates


Apply Trend Factor?

Use Employee Zips?

Yes—full time student or disabled dependent information requested if child over age.

*This does NOT include credit for the RX deductible



HMO

CalChoice® PPO 750 & CalChoice® PPO 1000

Active ChoiceSM 500†

CalChoice® PPO 2400, CalChoice® HSA 1500**

& CalChoice® HSA 2400 **

59

GENERIC VS. BRAND NAMEIf generic available, and doctor has not indicated“dispense as written,” will member receive ageneric equivalent rather than a brand namedrug?


SPECIAL CONCERNS*

Hearing treatment


PRESCRIPTIONS






HMO: Routine hearing screening in PCP's office only—office visit copay applies

PPO: Covers ear screenings to determine the needfor audiograms for dependent children throughage 18 only




Yes—subject to the Drug Formulary for the HealthCare Service Plan selected by member

* Unless otherwise noted, information shown in this section reflects in-networkbenefits.

* Information shown in this section reflects in-network benefits.** HSA-Qualified High Deductible Health Plan

Salud HMO y mas plan design varies depending onwhether the Salud provider network or the SIMNSAprovider network is utilized by the employee anddependents. The information outlined on this page only reflects the Salud provider network. Call your Word & Brown representative for Mexico benefit details.

CaliforniaChoice®

CaliforniaChoice®

CaliforniaChoice®


100% after copay

Office visit copay(ded. waived)

100% up to $500/ind.& $1000/family for allcategory 1 services


100% after copay



Office visit copay+80% immun. (ded. waived)

100% after copay




100% after copay




† After Active ChoiceSM 500 first dollar preventive care category 1 limit has been reached,member is responsible for all allowed charges until calendar year max. is reached. Once calendar year max. is reached, Blue Shield pays 100% of allowable amount

Note: CalChoice® HSA 2400 does not have an Rx card. Prescription drugs are covered - subject to calendaryear deductible and coinsurance. Member pays fullprice then submits prescription drug claims to BlueShield of California.

InfertilityHMO: $1500 lifetime maximum on infertility drugs.

Evaluation & treatment using coveredprocedures (no in-vitro fertilization)—50% ofallowed charges. Note: Covered procedures& allowed charges will vary by HCSP (HealthCare Service Plan).

See Evidence of Coverage or Benefit Booklet

PPO: Not Covered

Speech therapy

HMO: Outpatient covered if HCSP determines there will be significant improvement in 60 days—officevisit copay applies

PPO: Covered for certain conditions (see Evidence ofCoverage or call representative)—subject todeductible and coinsurance

Are Hearing Aids covered?No

CaliforniaChoice® now offers EPIC Hearing Service Plan(HSP) to all CaliforniaChoice® members at no additionalcost

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60


PRESCRIPTIONS

Can member self-referto an OB/GYN?

Allows OB/GYN to bePrimary Care Physician?

If generic available, anddoctor has not indicated“dispense as written,”will member receive ageneric equivalent ratherthan a name 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

BENEFIT SUMMARY

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

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

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

BlueShield HMO

Anytime

Yes

No

Yes—if OB/GYN in samemedIcal group/IPAas PCP

Yes—if OB/GYN islisted as PCP

Yes—or must paygeneric copay + difference in costbetween brand name & genericequivalent

Yes

Yes

Yes—if pre-approved

90 day supply—double the retail copayNo mail order benefit for non-formulary

Self: Yes—if usingAccess+ providerExpress: Yes—ifAccess+

No

Yes

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

Once amonth

HMO: Self: Yes— if Rapid Access provider

HMO: Yes— OB/GYN must be in same med grp/IPA as PCP

Yes—if OB/GYN is listed as PCP

Yes—or 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® HMO15:CalChoice® HMO 25:CalChoice® HMO 30:CalChoice® HMO 40:

CalChoice® HMO 25 Value:CalChoice® HMO 40 Value:

$10$15$15$20$15$15

$20 $100 Ded. - $25$150 Ded. - $30$200 Ded. - $35$200 Ded. - $30$250 Ded. - $30

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

25, CalChoice® HMO 25 Value, CalChoice® HMO 30, CalChoice® HMO

30 Value, CalChoice® HMO 40,CalChoice® HMO 40 Value,

Elect Open Access and Salud HMO y mas

Generic Brand Generic Brand

Elect Open Access:Yes—member may selfrefer to any doctor in PPOnetwork for a $40 copay

Elect Open Access: Yes

CaliforniaChoice®

CaliforniaChoice®

CaliforniaChoice®

Kaiser Permanente HMO

Generic Brand

Anytime—change is effective immediately

Yes—from KaiserPermanentePhysicians

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

Yes—to a KaiserPermanente OB/GYN

Yes

Yes

Yes

Yes —if deemed medicallynecessary by KaiserPermanente Physician

100 day supply—double the retail copay

No

Yes

$10$15$15$15

$20 $25 $30$30

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

Can family memberseach choose a PCPfrom 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?

HMO


WELL WOMAN BENEFITS

PPO 750, PPO 1000 & PPO 2400:$50 non-formulary copay*Active ChoiceSM 500:$50 non-formulary copay (or 50% of Blue Shield contracted rate)*HSA 1500* & HSA 2400*: $50 copay after plan deductible

61


CalChoice® HMO15:CalChoice® HMO 25:CalChoice® HMO 30:CalChoice® HMO 40:

CalChoice® HMO 25 Value:CalChoice® HMO 40 Value:

SharpHealth Plan

Once a month

Yes

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

Yes—on anunlimited basis in same IPA orPMG as PCP

Yes—if OB/GYN islisted asPCP

Yes—or must pay non-formularycopay

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

Word & Brown representative

No

Yes

Generic Brand

Double theformulary brand

copay




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



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





WELL WOMAN BENEFITS*

PRESCRIPTIONS


BENEFIT SUMMARYBENEFIT

SUMMARYPROVIDER INFORMATION


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 don't have togo through a specialist referralprocess

Yes—Negotiated Fee Reimbursement(NFR).

Yes—In a PPO, you can choose any OB/GYN anytime

Yes— In a PPO, there is no PCP. You can choose any OB/GYN anytime

Active ChoiceSM 500, PPO 750, PPO 1000 & PPO 2400Yes—or member pays the generic copay plus thedifference between the cost of the brand name &generic*

HSA 1500* & HSA 2400*:Yes—20% copay applies to brand name andgeneric after paying deductible

Blue Shield PPO

Active ChoiceSM 500, PPO 750, PPO 1000 & PPO 2400:Yes – non-formulary available at higher copay*HSA 1500* & HSA 2400*: Formulary does not apply

PPO 750, PPO 1000 & PPO 2400:Yes—$50 non-formulary copay*Active ChoiceSM 500:Yes—$50 non-formulary copay (or 50% of Blue Shield contracted rate)*HSA 1500* & HSA 2400*:Yes—Formulary does not apply

No

WesternHealth Advantage

Yes

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

Yes—anytime toan OB/GYNin the WHANetwork

Yes—in somecases

Yes—or must pay thebrand copay plus thedifference in costbetween the brandname and genericequivalent

Yes

Yes

90 day supply—double the retail copay

Yes

Once a month

CaliforniaChoice®

CaliforniaChoice®

CaliforniaChoice®

Active ChoiceSM 500, PPO 750, PPO 1000 & PPO 2400Yes*

HSA 1500* & HSA 2400*:20% copay applies to brand name and generic afterpaying deductible

*PPO 750- $150PPO 1000 - $200PPO 2400 - $250Active ChoiceSM 500 -$500 separate per individual Rxdeductible applies toformulary & non-formulary BRAND NAME drugs

BENEFIT SUMMARY

PPO


PPO 750, PPO 1000 & PPO 2400:90 day supply - $30/$60/$100*Active ChoiceSM 50090 day supply - $20/$60 or 30% whichever is greater /$100 or50% whichever is greater - Non FormularyHSA 1500* & HSA 2400*: 90 day supply-$30/$60/$100

$35 $50$50$50

CalChoice® HMO 40 Value $50

*HSA-Qualified High Deductible Health Plan

non-formulary:CalChoice® HMO 15: $70CalChoice® HMO 25: $100CalChoice® HMO 30: $100CalChoice® HMO 40: $100CalChoice® HMO 40 Value: $100

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DIABETIC BENEFITS

Are self-injectabledrugs (other thaninsulin) covered underthe Prescription Drugbenefit or MedicalBenefit?

BENEFIT SUMMARY

BlueShield HMO

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


CaliforniaChoice®

CaliforniaChoice®


Insulin


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


PrescriptionDrug Benefit

Some medicationsand/or dosagesmay requireprior authorization

No—not availablemail order



Covered under the Prescription DrugBenefit (Preferred monitors only) 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%Salud HMO y mas - 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%Salud HMO y mas - 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%Salud HMO y mas - 80%

Medical Benefit

Yes

No—use doctor'scontracted vendor



Durable MedicalEquipment Benefit





Must be prescribedby a planphysician

Must use planpharmacies(including affiliatedpharmacies)

62

HMO


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







* Subject to medical deductible if plan has one, and coinsurance. Does not have $2000 annual maximum of Durable Medical Equipment

63

SharpHealth Plan


Insulin



Needles & Syringes

Glucose Monitor


Insulin Pump










No—mail ordernot required

DIABETIC BENEFITS

BENEFIT SUMMARY

Blue Shield PPOWesternHealth Advantage

CaliforniaChoice®

CaliforniaChoice

SELF-INJECTABLE DRUG BENEFITS CaliforniaChoice®







PrescriptionDrug Benefit(in-network)


No—not availablemail order







Medical Benefit

Yes

Depends onmedical group

PPO


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

KEY TO HEALTH CARE SERVICE PLANSOFFERING LISTED PROGRAM

BS Blue Shield

HN Health Net

KP Kaiser Permanente

SH Sharp Health Plan

WH Western Health Advantage

* All CaliforniaChoice® medical members are eligible for discounts on eye exams, lenses, frames, andcontacts through the Vision One Eye Care Program administered by Cole Managed Vision/EyeMedVision Care.

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

2 Discounts on vitamins and herbal supplements available through the “Affinity Program” which linksKaiser Permanente members to Healthy Roads

3Member must use a Kaiser Permanente weight loss program.

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

Eyewear & lenses discount ..............................................................................................................................BS, HN, KP 1

Health Club Membership or fitness equipment/sporting goods discount…….......................................BS, HN, KP, WH

Health Literature, telephone tapes and/or videos (no charge)..................................................................BS, HN, KP, SH

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 ..............................................................................................................................BS, HN, KP, SH

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

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

DISCOUNTS, AWARDS & OTHER VALUE-ADDED BENEFITS (cont.)

BENEFIT SUMMARY

64


65

HMO & PPO Counties�



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Colusa

CalaverasMarin

Monterey

Sacra-mento

Alameda

AlpineAmador

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

Member Support 877-480-7923


Adds/Terms Fax 877 237-4519

Administrator Claims888-209-7847(Effective 11/1/09)

Banyan Consulting, LLC Attn: Tom Zimmerman 1215 Manor Drive, Suite 200Mechanicsburg, PA 17055 Phone 877-480-7923Fax 877-237-4519

Protect HSA 1500/3000Protect HSA 2500/2500Protect HSA 2850/5650

LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

PRODUCTS OFFERED

OPTIONAL BENEFITS

GROUP SIZE


HMO

66

CONSUMER-DIRECTED HEALTHCARE

HSA-CompatiblePPO



Is Workers' Comp required oncorporate officers, partners andsole proprietors?:

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

Is there a premiumadjustment for 24 hour coverage?:

HMOAnthem Blue Cross

PPOAnthem Blue Cross

No

Yes


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

Does carrier allow an OB/GYN to be Primary Care Physician?



24 HOUR COVERAGE


A member may change as frequently asdesired with a first of the month followingeffective date. However if a member is inthe middle of a treatment plan, say physicaltherapy with a Medical Group, they maynot switch to a different Primary CarePhysician (PCP) until the treatment plan has ended.

Yes

Yes

No

Only Well-Woman exams withinthe PCP Medical Group

SELECTION

NETWORKS

N/A

N/A

N/A

Yes

Yes

Yes

No

HMO Advantage 100HMO Value 80

2+

PPO

ProtectPlus 10ProtectPlus 15

ProtectPlus 15 EnhancedProtectPlus 25



No

California CPA

California CPA

California CPA


Employees

Dependents

Employees

Dependents



Union/Non-union?

Minimum group size




Employees

For Dependents

% of Total Cost:



PARTICIPATION

Min. # of employees

Max. # of employees

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE

AFTERINITIAL ISSUE

CARVE OUTS*

WRAP* REQUIREMENTS




67








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No

No

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

Yes

51% of the group’s employees must reside in California.Use the employer’s zip code for the out-of-stateemployees on the census

100%

100%

2+

2+ Yes (with Kaiser Permanente only)

2+ No—do not allow PPO wrap

50%

N/A

N/A

75%

N/A

2+

2 2

No max. No max.

Not allowed

Not allowed

Not allowed

2

No

Participation is available to the CA-based owners and employeesof accounting firms in public practice or offering generalfinancial services (SIC 8721). To be eligible and retain sucheligibility, more than 50% of all of the firms' owners (principals,partners, shareholders or other owners) must be CPA's or non-CPA members of CaICPA, and all CPA owners must be membersof CaICPA in good standing.

Non-student dependent children ages 19 through age 24 can becovered at employee rates. Call your Word and Brownrepresentative.

Groups can turn in apps for CalCPA membership withEnrollment. Membership ID# must be included on the MasterApp.

All employees who work at least 20 or 30 hours per week areeligible to enroll.

California CPA

California CPA

California CPA


Current Employees

TimelyAdd-ons

Group Size

Composite Rates

Rate Guarantee*

Apply Trend Factor?

Use Employee Zips?




















FEES






GROUP SIZE2+

RATING INFORMATION

68





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


N/A

Yes—1st of the month after date of hire—6 months max.

30 days

Yes

Yes—must submit copy of college transcript with initial enrollment

No

Yes

Yes—each November for a January 1 effective date

None

N/A

N/A

No

No

No

No

No

No

Yes

No

No

No

No

No

No

No

No

Yes

No

Non-Medical

No

N/A

No

No

No

Check not requiredwith submission

If husband and wife are both employees and they enroll separately,they need a W-2 to prove the spouse works there. If they are writtenas one, the CPA must be the primary insured

Non-Medical

HMO Automatic 1.10PPO Rate tables vary by

group size (2-14, 15-50)

Yes—51+

12 months

No

Yes

California CPA

California CPA

SPECIAL CONCERNS*

InfertilityCovered—Diagnosis and treatment of infertility, asmedically necessary, provided you are under treatmentof a physician. Artificial insemination and in vitrofertilization are covered; any drugs prescribed forinfertility and any laboratory procedures related to invitro are not covered

Not Covered—Any services or supplies furnished inconnection with the diagnosis and treatment of infertility,including, but not limited to, diagnostic tests, medication,surgery, artificial insemination, in vitro fertilization,sterilization reversal, and gamete intrafallopian transfer,except as specifically stated under “Infertility Treatment”provision of medical care that is covered


PRESCRIPTIONS



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








69


Hearing treatment


Speech therapy

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All Plans 100% after copayoffice visit copay

(deductible waived)up to $250 max.

Exempt from thedeductible, then

insured pays officevisit copay and

coinsurance, no limit







Not covered—routine hearing tests, except asspecifically provided under “Preventive Care” benefitsof medical care that is covered (Beneficiaries age 7 and older)

Yes—outpatient speech therapy following injury ororganic disease

No

No

No “dispense as written” override to get brand copaywhen generic available

N/A

Yes

Yes—using Prescription Drug Program

Yes

California CPA

California CPA

California CPA

DIABETIC BENEFITS


70



Insulin

Needles & Syringes

Glucose Monitor


Insulin Pump






*Must self-injectables(other than insulin)





Durable Medical Equipment Benefit





Yes NoHMO


No NoPPO

California CPA

California CPA

*Some injectables may be required to go through the Anthem Specialty Rx Program—call your Word & Brown representative

71

PPO Counties

All Plan Types


Plan may not be available in all zip codes within county. Check withyour Word & Brown representative toconfirm if coverage is available foryour group location.

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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

Member Support 800-361-3366Bilingual Support 800-331-1777Account Service & Membership Accounting Dept. 800-447-8812 Option 2 Benefits & Eligibility Dept. 800-224-8808 Option 3

(Mon.-Fri. 8:00 AM-4:30 PM PST)Enrollment Dept. 800-224-8808 Option 3

(Mon.-Fri. 8:00 AM-4:30 PM PST)For Group online access Eligibility you will need the Group Account number.

Federal COBRA Enrollments Fax 916-935-4420 (ATTN: COBRA)Release Authorization (for HIPAA Release Auth. Forms) Fax 916-935-4420 Precertification Department 800-977-7282 Broker of Record Changes/Group Termination Requests Fax - So Cal. 818-676-6297

Fax - No. Cal. 800-303-3110Caremark Pharmacy Services 800-600-0180, Option 1Client Management Dept.(for rates and service issues) 800-447-8812Adds/Terms Fax 916-935-4420Account Services 800-547-2967 (8 a.m.-5 p.m.)

or via email: [email protected]

Commissions 800-448-4411, Option 4�

Health Net Corp. Office21281 Burbank Blvd.Woodland Hills, CA 91367

ClaimsP.O. Box 14702Lexington, KY 40512

ADMINISTRATOR

Salud Mexico is available to groups located within 50 miles of the border

Salud EPO and Salud PPO plans areavailable to employer groups ormembers located in Los Angeles,Orange and Ventura Counties.

CLAIMS


Health NetFile 52617Los Angeles, CA 90074-2617800-224-8808, Option 3

BILLING

HMO/POS

The Silver Network isavailable in all or parts ofKern, Los Angeles, Orange,Riverside, San Bernardino,San Diego, San Franciscoand Ventura counties

Salud HMO y Mas is available toemployer groups or members located inOrange County and parts of Los Angeles,Riverside, San Bernardino and San DiegoCounties.

SIMNSA (for all plans)Mexico Service Area: Tijuana, Mexicali, Rosarito or Tecate



AvailableAvailable**Available**

Not Available

AvailableAvailable

Included if optional Chiropractic elected byemployer


LIFEDENTALVISION

INFERTILITY

CHIROPRACTICACUPUNCTURE

MASSAGE THERAPY

PRODUCTS OFFERED

OPTIONAL BENEFITS

GROUP SIZE


HMO/EPO PPO POS

72


HSA-Compatible PPO HRA-Compatible PPO

ALTERNATIVE DISCIPLINESIs on-the-job covered for corporate officers, partnersand sole proprietors?





2-50

Once a month within PMG/IPAPMG/IPA may be changed once a month

**Optional Health Net Dental & Vision plans available—call representative for details

Health Net

Health Net

HMO/EPO

HMO 10*†HMO 20*†HMO 30*†HMO 40*†EOA 10*†EOA 20*†EOA 30*†EOA 40*†Salud HMO Y Mas 15 1

Salud HMO Y Mas 25 1

Salud Mexico 3

Salud EPO 4

Options HMO 25Options HMO 35Options EOA 25Options EOA 35Hn Options Silver HMO 25Hn Options Silver HMO 35

PPO

PPO 10*PPO 20*PPO 30*PPO 40*Salud PPO 5

Options PPO 250Options PPO 500Options PPO 1500Options PPO 1750

POSPOS 10POS 20

INDEMNITYFlexNet 2

(Out of Area)

Value HSA 1500Value HSA 2500Value HSA 3500Value HSA 4500

Standard HSA 2000

Standard HSA 3000Standard HSA 4000

Options PPO 3000 HSAOptions PPO 4000 HSA

HRA 3000 HRA 5000

Hn Options (MIX AND MATCH) Health Net

Health Net

Is Workers' Comp required oncorporate officers, partnersand sole proprietors?

24 HOUR COVERAGE


Yes

HMO/POS: Yes—if medical groupoffers OB/GYN as PCP choice

PPO: N/A

HMO: Yes—OB/GYN visits only (OB/GYNmust be in same medical group as PCP)POS & ELECT Open Access: HMO (Tier 1)Yes—same as HMO above; PPO (Tier 2) YesPPO: Yes—no PCP selection required

Yes—if a Rapid Access Provider

Yes

No

No—all employees must haveWorkers' Comp except those notlegally required to be covered.Workers' Comp that is "pending” atthe time of sale is not acceptable

SELECTION

NETWORKS

For Salud Y Mas, only Los Angeles, Orange,Riverside, San Bernardino,San Diego and VenturaCounty network optionalbenefits are shown here.Mexico network benefits vary—call your Word & Brownrepresentative for details

HMOHealth NetSilver Network (all HMO and EOA Standard, andValue plans in Southern CA & San Francisco only)EOAHealth Net HMO/PPOPPOHealth Net PPOPOSHealth Net HMO/PPOSALUD Y MASLos Angeles, Orange, Riverside, San Bernardino and San Diego Counties: Call your Word & Brown

representativeVentura County: Salud Primero EPOMexico: Sistemas Medicas (Tijuana,

Mexicali, Nacionales, S.A de C.V., Rosarito & Tecate (SIMNSA)

1 Currently available to groups or members in Los Angelesand Orange Counties, and select zip codes of Riverside andSan Bernardino Counties

2 Not available on a standalone basis3 Available to groups who are within 50 miles of the border in

San Diego or Imperial Counties4 Currently available to groups or members in Los Angeles,

Orange and Ventura Counties only5 Available Los Angeles, Orange and Ventura counties

Groups of 5-9 enrolled employeesEach employee selects from the following plans:

Options HMO 35Options PPO 500, 1750, 3000 & 4000Salud HMO y Mas, PPO and EPO★

Salud Mexico ★

Flex Net ★


Options HMO 25 and 35Options PPO 250, 500, 1500, 1750, 3000 & 4000Options EOA 25 & Options EOA 35Salud HMO y Mas, PPO and EPO★

Salud Mexico ★

Flex Net ★

★ Service area restrictions apply. Call your Word & Brown representative for more details

†Each of these plans are available Silver.*Each of these plans are available either Standard or Value. Call your Word & Brown representativefor more details

Hn Options Silver (MIX AND MATCH) Health Net


Options HMO Silver 35Options PPO 500, 1750, 3000 & 4000Salud HMO y Mas, PPO and EPO★

Salud Mexico ★

Flex Net ★


Options HMO Silver 25 and 35Options PPO 250, 500, 1500, 1750, 3000 & 4000Salud HMO y Mas, PPO and EPO★

Salud Mexico ★

Flex Net ★


AFTERINITIAL ISSUE

Employees



Employees

For Dependents

% of Total Cost:



PARTICIPATION

Contributory

GROUP SIZE

GROUP SIZE

WRAP* REQUIREMENTS



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Yes—if employed on a full-time basis for a minimum of 3 months andmeeting the hour per week requirement & probationary periodindicated on the Group Service Agreement. DE-6 earnings must bereported & employee must have workers' comp. If employee is newand does not appear on last quarter's DE-6, submit payroll records.

Yes—if the group first meets AB1672 and 1099 employee is affiliatedwith group long enough to be tied to company through a federal taxreturn & can meet the definition of a full-time employee. This can bedemonstrated in the form of one Schedule C and Form 1099-Miscfrom the most recent year.

Emergency coverage only

Yes—groups of 2-50 eligible employees with over 50% of the totalgroup located in CA are subject to the out-of-area requirementsoutlined below. Coverage not available in Hawaii.

Up to 49% (including and/or excluding COBRA) of total eligiblepopulation may be written on an out-of-state PPO plan. Of the 49%,only those employees who are out of the out-of-state PPO servicearea may be written on a Flex plan. Coverage not available in Hawaii.



Non-Contributory

STANDARD WRAP* REQUIREMENTS

◆◆75%

Single/Enhanced/

Silver Choice

◆◆ Those covered by another employer group plan are NOTconsidered eligible in calculating participation. In order to NOT be considered eligible, the other coverage must be an employer group plan or MediCal/Medicare

* AB1672 group of 2 with one valid waiver due to other coverage† 51-59 available. Group must have less than 50 employees for more than

50% of last quarter or last year.

In order to be considered guaranteed issue, the group must meet all 3 of these criteria:1) Must have had between 2 and 50 employees for at least 6 weeks

prior to the effective date.2) More than 50% of the group must be located in California;3) Both the carve-out and non-carve-out populations must be offered

group coverage

CARVE OUTS* Health Net



Union/Non-union?

Minimum group size

Does carrier underwrite and rate carve outgroups according to AB1672 guidelines?

†Group size is based on number of active enrolling employees*Indicates flexibility in being offered with products of another carrier.

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

PPO or indemnity plan?

Single Option 2-50

N/A

Yes—Health Net must be the only carrier offered to the carve out population. TheDE-6 and/or payroll must clearly define the class of employees which may beselected from (i.e. carved out) the entire group. Carve out may or may not beguaranteed issue based on criteria shown below. Individual Health statements arerequired on all carve outs

Yes—see requirements above

Employer does not pay directly toward union health plan: Yes—if Health Net is sole carrier for carve out and submits letter from group or broker oncompany letterhead that includes: 1) Describes basis for carve out; 2) Includesname and SSNs of those eligible; 3) Indicates if non-carve out population is offeredcoverage elsewhere; 4) Indicates employer does not contribute directly to unionhealth plan, but only pays toward union dues. No health statements required.Employer pays directly toward union health plan: Yes—if Health Net is solecarrier for carve out and group/broker submits a letter with all items outlined aboveexcept #4. This letter must indicate that employer contributes directly to unionhealth plan. Health statements are required.

2 eligibles, 1 enrolling, 1 valid waiver

1* 150 † 50 †

Hn Options 5-50Hn Options Silver 5-50Enhanced Choice 2-50

Silver Choice 2-50

$100 or 50% of lowest cost plan EE

rate (excluding Salud)

N/A

N/A

H n Options

2-5† Not eligible6-50 † HMO/HMO Silver/EOA: Yes—on a single plan choice

basis. 50% with a minimum of 6 must enroll with HealthNet. POS & PPO: Yes—on a single plan choice basis. 75%with a minimum of 6 must enroll with Health Net.Enhanced Choice/Silver Choice: Yes—75% with aminimum of 6 must enroll with Health Net

Minimum 5 enrollingemployees for 10 planpackage, and minimum10 enrolling employeesfor 15 plan package.75% of eligibleemployees must becovered by employerwith H n Options oranother carrier plan

Dependents N/A

N/A

Same requirement as contributory (see above)Employees

Dependents

◆◆75%

N/A

50% of lowest costplan EE rate

(excluding Salud)

N/A

N/A

Hn OPTIONS:

2-4† Not eligible5-9† Yes—10-plan package: 75% of eligible employees must be

covered by employer with Hn Options, Hn Options Silver oranother carrier's group plan.

10-50 † Yes—15-plan package: 75% of eligible employees must becovered by employer with Hn Options, Hn Options Silver oranother carrier's group plan.

Hn OPTIONS/Hn OPTIONS SILVER* WRAP REQUIREMENTS

†Group size is based on number of active enrolling employees*Indicates flexibility in being offered with products of another carrier.

Hn Options Silver

Minimum 5 enrollingemployees for 10 planpackage, and minimum10 enrolling employeesfor 13 plan package.75% of eligibleemployees must becovered by employerwith H n Options oranother carrier plan

N/A

N/A

Can be written with another carrier's HMO,EOA, POS, EPO, PPO or indemnity plan?

GROUPSIZE

Hn OPTIONS SILVER:

2-4† Not eligible5-9† Yes—10-plan package: 75% of eligible employees must be

covered by employer with Hn Options, Hn Options Silver oranother carrier's group plan.

10-50 † Yes—13-plan package: 75% of eligible employees must becovered by employer with Hn Options, Hn Options Silver oranother carrier's group plan.

Can be written with another carrier's HMO,EOA, POS, EPO, PPO or indemnity plan?

GROUPSIZE


Composite Rates


Apply Trend Factor?

Use Employee Zips?


Current Employees

TimelyAdd-ons




















FEES






GROUP SIZE

RATING INFORMATION

74





Medical Conditions/# of Pregnancies

Years in Business/Virgin Group

Plan(s) Requested


Participation/Gender Mix

Type of Industry

% Percent of Owners or Family Related

Group Size

% of COBRA Insureds

24 HR Coverage Req'd/Bankruptcy

1st of the month—15th OK if prior group coverage ends on 15th

1 1/2 months premium

Min: 1st of month following hire Max.: 6 months

60 days

Yes—if valid waivers is more than 50% of eligibles

Yes

No

Yes

Yes—open enrollment allowed at renewal

Yes

No—unless new company †

No

No

Yes

Health Net

None

N/A

None

† Minimum 6 weeks of payroll records required

2-5 6-9 10-50

Non Full Master AppMedical Medical (Employer

Questions)*

Non Non NonMedical Medical Medical

Yes

No

No

No

No

Yes

No

Yes

No

Health Net

Health Net

If both domestic partners and spouses are eligible as employees they canopt to enroll on one application together or separately with Health Net

HMO: N/AIndemnity, PPO & POS: Yes

HMO: N/AIndemnity, PPO & POS: Yes

2-5: Automatic 1.106-9 : Guaranteed .90 if group meets

RAF Special Program criteria. If not,RAF assigned in .01 increments.

10-50: Guaranteed .90 if group meets RAFSpecial Program Criteria. If not,RAF assigned in .01 increments.

Available on HMO, ELECT Open Access, POS and Salud HMO Y Mas plans with aminimum of 10 enrolled employees on agiven plan

12 Months

No

Yes

Not available for Enhanced Choice or SilverChoice groups (H n Options, H n OptionsSilver or PPO & FlexNet subscribers)

Yes—20% or more gets automatic 1.10

(Unless group eligiblefor an industry discount)

* If employer gives name of an employee in response to one of these questions, an Individual Health Statement must be submitted by that employee

HMO, ELECT OpenAccess & POS

75



FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?Yes—Health Net refers to this as their RecommendedDrug List

Are non-formulary drugs available?Yes—$50 non-formulary copay

MAIL ORDER - 90 DAY SUPPLYMail order is covered at twice the retail copay

Are oral contraceptives covered?Yes

Hearing Treatment

Yes—member will receive generic unless brand is requested. If brand is requested by member, the memberwill pay the brand copay plus the difference in costbetween the brand and generic

Yes


SPECIAL CONCERNS*


PRESCRIPTIONS




Health Net

Health Net

Health Net

Prescriptions filled at a non-participating pharmacy will have aseparate $100 deductible per member and 50% coinsurance.

PPO, EOA, & HMO Value plans: Brand Name deductible

Options Plans (all): $200 brand deductible per member percalendar year

100% after officevisit copay—periodichealth evaluation only

100% birth throughage 2. 100% after office

visit copay age 3-17

100% after office visit copay on Tier 1 only; Tier 2 covered

with coinsurance

HMO: Covered in fullPOS: Coinsurance

PPO (All)

100% after officevisit copay—Max. $250/year for

routine physical exam

100% after office visit copay


PPO 10, 20, 30, 40 & Options PPO:Applicable plan deductible &

coinsurance appliesCovered as part of annual exam

Salud Mexico's plan design cannot be clearly outlined on this page. Please call your Word & Brown sales representativefor details.

HMO: Routine hearing screening in PCP's office—office visit copay

EOA: Tier 1: Covered as outlined above for HMO. Plan 10—$10; Plan 20—$20; Plan 30—$30; Plan 40—$40 office visit copayTier 2: Plan 10—$35; Plan 20—$35; Plan 30—$45; Plan 40—$55 office visit copay

POS: Covered on Tier 1 only (See HMO entry above)PPO: (All) Routine preventive exams only through

age 16;


InfertilityStandard & ValueHMO and EOA, Options HMO & Options EOA: 50% copay - includes professional services,

inpatient/outpatient care, treatment by injection/prescriptiondrugs & artificial insemination. GIFT, ZIFT, IVF, IFT notincluded

POS: Covered as outlined above on Tier 1 only. GIFT, ZIFT, IVF &IFT not included on either Open Access or POS. Artificialinsemination not covered on POS

PPO Standard & Value, Value HSA 1500, 2500, 3500 & 4500, Standard HSA 2000, 3000 & 4000: Applicable coinsurance applies. Calendar year deductible—

$500; Lifetime max: $2000

Options PPO 250500, 1500, 1750,3000 HSA & 4000 HSA: Applicable coinsurance applies. Calendar year deductible—

$500; Lifetime max: $2000

Speech TherapyHMO: Office visit copay—provided as long as

significant improvement is expected

Options EOA: Office visit copay—maximum 12 visits per year (Tier 1 & Tier 2 combined)

Open Access& POS: 100%—as long as significant improvement

expected (Tier 1)

PPO: Applicable coinsurance applies/max. 12 visits per year (combined for PPO & out-of-network)— outpatient only


All PPO Plans: GIFT, ZIFT, artificial insemination, IVF & IFT not covered

Options HMO 100% after officevisit copay—periodichealth evaluation only

100% birth throughage 2. 100% after office

visit copay age 3-17


HMO:100% (no copay)

Salud con Health Net plan design varies depending onwhether the Los Angeles, Orange and Ventura Countyprovider network or the Mexico provider network is utilizedby the employee and dependents. Therefore, the benefitinformation cannot be outlined on this page. Please call yourWord & Brown sales representative for details.

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DIABETIC BENEFITS


76





Insulin

Needles & Syringes

Glucose Monitor


Insulin Pump









For the most up-to-date information onHealth Net's programs, go to

www.healthnet.com

Health Net

Health Net



Prescription Drug or Durable Medical Equipment Benefit depending on brand




Medical Benefit

Medical Benefit

Medical Benefit

Yes

Yes

Yes

No—doctor'scontracted vendor

HMO tier: doctor’scontracted vendor;

PPO tier: pre-cert. applies,carrier-contracted vendor

is optional

Pre-cert. applies, carrier-contracted vendor

is optional

HMO plans:

POS plans:

PPO plans:

Health Net

Health Net

Copayments for self-injectables go towards OOP max. on all plans

77

PPO Counties


Plan may not be available in all zip codes within county. Check with your Word & Brown rep to confirm if coverage is available for your group location.

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

Member Support,Customer Service,Commissions

Adds/Terms

Claims

Allied National800-825-7531

Fax 816-221-4638

Allied National-Global CareEDI# 07689PO Box 247Alpharetta, GA 30009-0247

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�


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

Does carrier allow an OB/GYN to be Primary Care Physician?



Is Workers' Comp required oncorporate officers, partners andsole proprietors?:

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

Is there a premiumadjustment for 24 hour coverage?:

LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

PRODUCTS OFFERED

OPTIONAL BENEFITS

GROUP SIZE


PPO

78


HSA-CompatiblePPO

HRA-CompatiblePPO

MRP-CompatiblePPO



Kern & Santa Barbara Counties:Foundation for Medical Carewww.cfmcnet.org

All other counties: Interplanwww.interplanhealth.com

Mexico: SIMNSAHospital Santa Margarita San Luis Rio

No

No

Referrals not required

Referrals not required

Available

N/A

N/A

N/A

Covered with limits

Covered with limits

Covered with limits

HealthEdge Cost Saver

N/A

No

Yes Yes

24 HOUR COVERAGE


PCP not required

SELECTION

NETWORKS

PCP not required

PCP not required

Plans administered by Allied National, underwritten by American Alternative Insurance Corporation (A+ Rated)

and reinsured by Munich-RE America Corporation.

HealthEdge

HealthEdge

HealthEdge


Employees

Dependents

Employees

Dependents



Union/Non-union?

Minimum group size




Employees

For Dependents

% of Total Cost:



PARTICIPATION

Min. # of employees

Max. # of employees

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE

AFTERINITIAL ISSUE

CARVE OUTS*

WRAP* REQUIREMENTS




79







Max. % of employees residing out-of-stateallowed

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Yes—must work exclusively for employer

Yes—must work exclusively for employer

Yes—limited to 30 days

Yes

50% when employees are in: CO, GA, IA, IL, IN, KS, MO, NE, NV, OH, OK, PA, TN & TX. 25% in all other states

100%

N/A

2+

2+ Cost Saver only

2+ Cost Saver only

25%

N/A

N/A

75%

N/A

2+

2 2

N/A N/A

Yes—participation based on included classes only

Yes

Yes

2

Yes

1. No medical underwriting is required

2. No well baby benefit coverage is included

3. Multiple locations need home office approval—contact yourWord & Brown representative

HealthEdge

HealthEdge

HealthEdge


Current Employees

TimelyAdd-ons

Group Size

Composite Rates

Rate Guarantee*

Apply Trend Factor?

Use Employee Zips?




















FEES






GROUP SIZE

RATING INFORMATION

80





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

Any day of the month

Yes—submit one month’s premium

Minimum: 0 days; Max: 180 days

On or before requested effective date

2 apps—husband & wife groups—not guaranteed issue

Yes

No—coverage ends at age 24 regardless of student status

Yes

No

Yes—at anniversary

N/A

N/A

Call rep

No

No

No

No

Yes

No

Yes

No

No

Yes

No

No

Yes

No

No

Yes—in same calendar year

No

Non-Medical

Yes

Yes

No

Yes

Yes

Allied National

Non-Medical

2-100; over 100 livesrequires approval

For groups of 15+

12 Months

Yes

No

2+

HealthEdge

HealthEdge

SPECIAL CONCERNS*

Infertility


PRESCRIPTIONS










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

81


Hearing treatment


Speech therapy

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Infertility

Physicians diagnosis or treatment of infertility:$500 lifetime benefit

Cost Saver N/A Subject to office visit benefit

10 visits per calendar year

10 visits per calendar year

No

Generic offered. If member chooses brand they pay thecost difference between generic and brand

Formulary only

Yes

Same

2X copay

Yes

HealthEdge

HealthEdge

HealthEdge

DIABETIC BENEFITS

These services may change at any time without notice. Please contact your Word & Brown rep for specific inquiries on listed services

82



Insulin

Needles & Syringes

Glucose Monitor


Insulin Pump















If available through pharmacy, covered

under Rx Benefit

Yes NoFormulary Plans Only

HealthEdge

HealthEdge

83


Colusa

CalaverasMarin

Monterey

Sacra-mento

Alameda

AlpineAmador

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 �PPO Only Counties

HMO & PPO CountiesPlan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.

Billing

Health Net 800-361-3366Western Health Advantage 888-563-2250Kaiser Permanente

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

HSA California ® Customer Service 866-251-4718

HSA CaliforniaBenefit Administrators721 South Parker, Ste. 200Orange, CA 92868

Broker Services &Commissions

Member Support

714-542-6992 - Ext. 4390

The following HMOs have an “Excellent” rating from the NCQA

for their commercial products:

Kaiser Permanente (HMO)Western Health Advantage (HMO)


Administrator

HSA CaliforniaBenefit Administrators721 South Parker, Ste. 200Orange, CA 92868

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

HMO

Available

Buy-up

Discount or Buy-up

Not Available

Varies by HCSP

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)

OPTIONAL BENEFITS

GROUP SIZE


HSA California

HSA California®

HSACalifornia

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 pages 88-89)

Varies by Health Care Service Plan (See summary on pages 88-89)

HMO 1800HMO 2200HMO 2600

HMO 2800B

PPOPPO 2500PPO 3500PPO 4500

SELECTION

NETWORKS


85


Employees

Dependents

Employees

Dependents


Are Commission employees allowed?





*100%

N/A N/A

2-2 3-50


No


Yes*— PPO 2500, PPO 3500, PPO 4500

* Except for employees in Hawaii

49% (Main office must be located in California)

2-50


N/A

N/A

2 250* N/A

2-50 No

2-50 No

*100% ◆70%

N/A N/A



or more


Employees

For Dependents

% of Total Cost:



PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE


WRAP* REQUIREMENTS






†

HSA California®

HSA California

HSA California

HSA California

AFTERINITIAL ISSUE



No

No


2

Yes



Union/Non-union?

Minimum group size


* 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) M

ED

IC

AL

86



Current Employees

TimelyAdd-ons




















FEES



Monthly Billing Fee



GROUP SIZE


RATING INFORMATION




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


N/A

Min: 30 Max: 365

60 days


Yes

Yes

Yes


Yes

Call representative

Yes*

Yes*

Yes

HSA California

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 .90. See quote for details.

N/A

12 Months

No

HMO: YesPPO: Yes

2-14 15-50




HSA California®

HSA California


HMO: N/APPO: Yes*

No


Composite Rates


Apply Trend Factor?

Use Employee Zips?

Yes—full time student or disabled dependent information requested if child over age.

*This does NOT include credit for the RX deductible


87


Refer to summary on page 88

HMO 1800

SPECIAL CONCERNS*

Hearing treatment

PREVENTIVE BENEFITS1,2

PRESCRIPTIONS



HMO: Routine hearing screening in PCP's office only—office visit copay applies

PPO: Covers ear screenings to determine the needfor audiograms for dependent children throughage 18 only

* Unless otherwise noted, information shown in this section reflects in-networkbenefits.

1 Information shown in this section reflects in-network benefits.2 Not subject to deductible

HSA California®

HSA California

HSA California

No Charge No Charge No Charge No Charge

HMO 2200 $20 copay $10 copay $20 copay $10 copay

HMO 2600 $30 copay $10 copay $30 copay $10 copay

HMO 2800B $40 copay No Charge No Charge No Charge

PPO 2500 $25 copay $25 copay $25 copay $25 copay



InfertilityNot Covered

Speech therapyHMO: Outpatient covered if HCSP determines there

will be significant improvement in 60 days—office visit copay applies

PPO: Covered for certain conditions (see Evidence ofCoverage or call representative)—subject todeductible and coinsurance


HSA California now offers EPIC Hearing Service Plan(HSP) to all HSA California members at no additionalcost

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$20 generic/$40 brand




88



PRESCRIPTIONS




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



Mail order

BENEFIT SUMMARY

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




HSA California®

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

Anytime

Yes

Yes

Yes

Yes

No

Yes





WELL WOMAN BENEFITS

HMO 2200$20 Generic$40 BrandHMO 2600

$20 Generic$60 Brand

Western HealthAdvantage HMO

Once a month,effective for the following month

Yes

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

Yes

No In a PPO, you do not have tochoose a PCP

Yes—or you mustpay the brand copayplus the differencein cost between brand name &generic equivalent

Yes

No

Yes

HMO 1800No Charge

HMO 2800B$20 Generic$60 Brand

$100 Non-Formulary

HMO 1800No Charge

HMO 2800B$50 Copay

Yes

Health NetPPO

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

Yes—each familymember can maketheir own physicianchoice

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

In a PPO, youchoose anyOB/GYNanytime

Yes—or you mustpay the brand copayplus the 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

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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®




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





Must be prescribedby Plan physician, inaccord with our drugformulary guidelines

Must use planpharmacies(including affiliated pharmacies)



Prescription Drug Benefit (preferredmonitors only) All other monitors covered as Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% Up to max $2,000PPO 4500:In-Network: 60% Out-of-Network: 40% Up to max $1,000


Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% Up to max $2,000PPO 4500:In-Network: 60% Out-of-Network: 40% Up to max $1,000

Durable Medical Equipment PPO 2500 & 3500:In-Network: 70% Out-of-Network: 50% Up to max $2,000PPO 4500:In-Network: 60% Out-of-Network: 40% Up to max $1,000

Medical Benefit

Yes—required through Pharmacy

May use mail order vendor or contractedpharmacy 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

90


KEY TO HEALTH CARE SERVICE PLANSOFFERING LISTED PROGRAM

HN Health Net

KP Kaiser Permanente

WH Western Health Advantage

* All HSA California ® medical members are eligible for discounts on eye exams, lenses, frames, andcontacts through the Vision One Eye Care Program administered by Cole Managed Vision/EyeMedVision Care.

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

2 Discounts on vitamins and herbal supplements available through the “Affinity Program” which linksKaiser Permanente members to Healthy Roads

3Member must use a Kaiser Permanente weight loss program.

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

Eyewear & lenses discount......................................................................................................................................BS, 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 (cont.)

BENEFIT SUMMARY

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

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AdministratorSee address under map

Emergency Claims Addresses

Southern CaliforniaKaiser Foundation Health Plan, Inc.Claims DepartmentP.O. Box 7004Downey, CA 90242-7004

Northern CaliforniaKaiser Foundation Health Plan, Inc.Claims DepartmentP.O. Box 12923Oakland, CA 94604-2923



Member Claims 800-390-3510

Release Authorization(for HIPAA Release Forms) Fax 858-614-3345

Customer Service 800-790-4661

Spanish Member Support 800-788-0616


Adds/Terms No. Cal. Fax 858-614-3344So. Cal. Fax 858-614-3345

Kaiser PermanenteHealth Plan393 E. Walnut St.LSRS-4Pasadena, CA 91103

NOTE: The Kaiser Permanente material is included in this reference guide for your convenience. Word & Brown does not have a contract. Please submit your Kaiser Permanente business direct.

All Plan Types

Claims


PRODUCTS OFFERED

OPTIONAL BENEFITS

GROUP SIZE


92


HSA-Compatible PPO HRA-CompatiblePPO

MRP-CompatiblePPO



How often can members changetheir Primary Care Physician (PCP)?



DUAL OR MULTI OPTION Boxes containing a “●” indicate that these coordinate plans offered by this carrier canbe written together to create a dual or multi option package. Blank boxes indicatewhich plans cannot be written together.

Kaiser Permanente

Is Workers' Comp required oncorporate officers, partnersand sole proprietors?

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

OB/GYN: Yes

Other Specialties: Yes—to certain specialties. Self-refer specialties listvaries by geographical region

Not Available

Available

HMO: Benefits vary by planPOS: Exam included on Tier 1 (HMO) only

HMO: Benefits vary by plan*POS: Optional rider*

Optional Rider

Not Available

Not Available

2-50

Kaiser Permanente—HMO &POS (Tier 1 only)

Private Healthcare Systems (PHCS)

No

No

Yes

PRODUCTS OFFERED

OPTIONAL BENEFITS

GROUP SIZE


CaliforniaChoice

Kaiser Permanente

KaiserPermanente

HMO/EPO

LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

*See “Special Concerns” Section on page 95 for details.

1 Southern California/Northern California2 Available only through the multiple plan offering. A prospect that chooses this plan must pair it

with a copayment plan (see chart below).3 See Special Considerations on page 93 for important requirements for PPO.4 If employer elects the POS plan, employees must enroll in either the HMO Plan or 3-tier POS

$5 Copayment Plan S/N 1





$30/$1000 Deductible Plan S/N 1

$30/$1500 Deductible Plan 2


24 HOUR COVERAGE


Plan 5*

Plan 15*

Plan 20*

Plan 30*

Plan 5 Plan 15 Plan 20 Plan 30

$35 POS Plan

$30/$1000

★

$30/$1500

Express referral available?Yes—referral direct from physician

Kaiser Permanente


Anytime—change is effectiveimmediately

Yes:HMO: From Kaiser PermanentePhysiciansPOS: From Private HealthcareSystems (PHCS)

Yes

★

* These HMO plans cannot be written together as a dual option package unless group creates a management carve-out. Then, one HMO plan may be selected by employer for all management and another HMO plan for all non-management.If employer elects the POS plan, employees must enroll in either the HMO Plan or 3-tier POS.

● Enhanced Choice multi-plan offering with 8 HMO plan designs available to groups of 3+ enrolling employees. Minimum employer contribution is 50% of the employee-only rate for the under-30 age band based on the lowest premium plan selected.

2 Available only through the multiple plan offering. Must pair it with a copayment plan.† PPO must be offered with one or more copayment plans. If offered with two or more plans, standard MPO rules apply.

70% must be enrolled under 2 HMO/DHMO plans and no more than 30% of eligibles can be on the PPO.

SELECTION

NETWORKSPOS

$35 POS Plan4

$30/$2700 Deductible Plan with HSA$0/$2700 Deductible Plan with HSA$0/$1500 Deductible Plan with HSA

$40/$2,500 Deductible Plan with HSA$0/$2,200 HSA Comp plan

$30/$2,500 Plan with HRA3

$30/$1,500 Plan with HRA3 N/A

$30/1500 Deduct. Plan2

Plan 50*

Plan 50

●

●

●

●

●

●

●

●●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

●

● ● ● ● ●●


PPO$40/$1000 PPO Plan3

PPO:$40/$1000$30/$2500$30/$1500

●†

●†

●†

●†

●†


Employees

Dependents

Employees

Dependents



Union/Non-union?

Minimum group size









Employees

For Dependents

% of Total Cost:



PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE

AFTERINITIAL ISSUE

CARVE OUTS*

WRAP* REQUIREMENTS





93

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1* 1*

50 50

50%

N/A

N/A

◆◆ 70% on any group plan

N/A

2-50

2-50HMO & POS

*In California, a minimum of 1 must enroll. At least 70% ofgroup's eligible employee population should be covered byeither a group health plan or Medicare.

Employees are eligible for coverage if they live or work withinthe Kaiser Permanente service area zip codes.

3 PPO cannot be sold as a standalone plan. PPO must beoffered with one or more copayment plans. PPO may not besold along with Chiropractic rider with any DeltaCare HMOplans.

For PPO+2 or more copay plans standard MPO rules apply.

*See special considerations below


◆◆ In order to NOT be considered eligible, the other coveragemust be a group plan (i.e. through their employer or their spouse's employer) or Medicare

Yes—must be a full time employee, have an employer/employee relationship and have workers' comp coverage. Need to submit DE-6 for proof

No

Yes—for emergencies only

Yes

51% of eligible employees need to reside in CA

Yes

Yes

Non-union only

2

Yes

2-50 Yes—for HMO and POS plans only. 70% of group’s eligible employee populationshould be covered by a group health careplan. If a group chooses a PPO, they cannothave another carrier written alongside.

2-50 Yes—for HMO and POS plans only. 70% of group’s eligible employee populationshould be covered by a group health careplan. If a group chooses a PPO, they cannothave another carrier written alongside.

Kaiser Permanente

Kaiser Permanente

Kaiser Permanente


Min. # of employees

Max. # of employees

2-50PPO+1 or PPO+2copayment plans

At least 70% of members must beenrolled under HMO/DHMO & up to 30%of members can be enrolled in the PPO

plan (combined PPO and POS members)

N/A

◆◆ 70% on any group plan

N/A

At least 70% of members must beenrolled under HMO/DHMO & up to 30%of members can be enrolled in the PPO

plan (combined PPO and POS members)

N/A

NonMedical

Non Medical



Current Employees

TimelyAdd-ons










FEES






GROUP SIZE


RATING INFORMATION

94



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

N/A

N/A

N/A

1st of each month

N/A

Min: 1st of the month following date of hire

Max: 1st of the month following 2 years of employment

30 days

2 separate applications

Yes

Yes

No

Yes

Yes—30 days prior to renewal date

2-5

NonMedical

Non Medical

Kaiser Permanente

Kaiser Permanente

N/A

N/A











6-15Yes

No

Yes

No

No

No

Yes

No

No

No

No

No

No

No

No









Yes*

Yes†

No

No

No—but they do need a copy of checkKaiser Permanente

16-50

NonMedical

Non Medical

*Must also submit payroll records for employees hired after DE-6 filing†If company has not been in business for at least 50% of the previous calendar quarter/calendar year, Kaiser Permanente will recertify these groups at their one year anniversary


2-5 Automatic 1.106-15 Automatic 1.0016-50 Automatic .90

Not Available

12 Months

No

No—except when employer isout of service area butemployees reside within it.Call Kaiser Permanente formore details


Composite Rates


Apply Trend Factor?

Use Employee Zips?


SPECIAL CONCERNS*

Infertility


PRESCRIPTIONS










95

Hearing treatment

Are Hearing Aids covered? ME

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HMO: Coverage includes medical examinations of theear and audiometric examination to measurehearing acuity.

POS: Exams covered on Tier 1 (HMO) only

HMO: Covered if deemed medically necessary byHealth Plan physician

POS: Limited coverage; please see Certificate Book or contact Health Plan representative

Copayment HMOs

POS





HMO: YesPOS: Yes

HMO: Yes—if deemed medically necessary by PlanPhysician

POS: Yes—$40 non-formulary copay applies. Select prescription medications are excluded from out-of-network coverage

HMO & POS: Yes—for 100 pills or 100 day supply;whichever comes first

Kaiser Permanente

Kaiser Permanente

Kaiser Permanente

100% after copay 100% after copayimmunizations: no charge

100% after copay 100% after copay

Deductible HMOs Copay-Ded. waived Copay-Ded. waived/immunizations: no charge

Copay-Ded. waived Copay-Ded. waived


Covered on Tier 1(HMO) only:

100% after copay atHealth Plan facilities

Covered on Tier 1(HMO) only:

100% after copay at HealthPlan facilities

20% copay 20% copay

HMO: YesPOS: Yes


HMO: YesPOS: Yes—if brand name is on Health Plan

Formulary

$30 Copay Plan, $10/$1000 Ded. Plan, $20/$1000 Ded. Plan &the $30/$1000 Ded. Plan have a separate $250 brand namecalendar year deductible per member

HMO: YesPOS: Yes

HMO Plan 5 & 15: 50% for diagnosis and treatment of cause

of infertility. Please see EOC forexclusions and limitations.

HMO Plan 20 & 30: Not covered

POS: Limited coverage on HMO tier only;please see Certificate Booklet or callHealth Plan representative. No coverageon PPO or out-of-network tiers.

Speech therapy

No

DIABETIC BENEFITS


96





Insulin

Needles & Syringes

Glucose Monitor


Insulin Pump









Kaiser Permanente

Kaiser Permanente

Kaiser Permanente









No—must be prescribedby a plan physician

No

Must use planpharmacies (includingaffiliated pharmacies)

No—levels of coveragemay differ

HMO plans:

POS plans:

Colusa

CalaverasMarin

Monterey

Sacra-mento

Alameda

AlpineAmador

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

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Member SupportKaiser Permanente Choice SolutionCustomer Service Center 800-580-9626

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

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

Commissions 800-542-4218, Ext. 4390


AdministratorCHOICE Administrators®

721 South ParkerSuite 200Orange, CA 92868

ClaimsKaiser PermanenteClaims800-464-4000

Plan may not be available in all zip codes within county. Check with your Word & Brown representative to confirm if coverage is available for your group location.�All Plan Types Available

HMO, POS, PPO & Indemnity

PPO & Indemnity Only

LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

PRODUCTS OFFERED

OPTIONAL BENEFITS

GROUP SIZE


HMO/EPO PPO POS

98


HSA-CompatiblePPO

HRA-CompatiblePPO

MRP-CompatiblePPO



Available

Available

Not Available

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

Not Available

Not Available

Not Available

HMO 10HMO 30

HMO 20/$1,000

N/A

30/$500PPO HSA 2200*

20/$1,00030/$1,500

INDEMNITYIndemnity

HDHP 1400*HDHP 2400*

N/A

Kaiser Permanente Choice Solution


2-50Is Workers' Comp required oncorporate officers, partners and sole proprietors?

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

Is there a premium adjustmentfor 24 hour coverage? No



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

POS/PPO: From PHCS Network

Does carrier allow an OB/GYNto be Primary Care Physician?Yes

HMO/EPO

Kaiser Permanente

POS/PPOPrivate Healthcare Systems (PHCS)

Anytime—change is effectiveimmediately

No

24 HOUR COVERAGE


OB/GYN: YesOther specialists: Yes—to certainspecialties. Self-refer specialtieslist varies by geographical region

Yes—referral direct from physician


SELECTION

NETWORKS

*HSA-Qualified High Deductible Health Plan

* 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)


Employees

Dependents

Employees

Dependents



Union/Non-union?

Minimum group size



Employees

For Dependents

% of Total Cost:



PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE


WRAP* REQUIREMENTS




99







Max. % of employees residing out-of-stateallowed

ME

DI

CA

L

*100%

N/A N/A


No


Yes

49% (At least 51% of eligible employees must live or work in California)

2-50


N/A

N/A

2 250* N/A

2-50 Yes—contact your Word & Brown representative regarding guidelines

2-50 Yes—contact your Word & Brown representative regarding guidelines

*100% ◆70%

N/A N/A



or more

No

No


2

Yes

2 250* N/A

AFTERINITIAL ISSUE



2-2 3-50






Current Employees

TimelyAdd-ons

Group Size

Composite Rates


Apply Trend Factor?

Use Employee Zips?




















FEES



Monthly Billing Fee



GROUP SIZE

RATING INFORMATION

100





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

N/A

Min: 1st of the month following date of hire Max: 365 days

60 days


Yes

Yes

Yes


Yes

Call representative

Yes*

Yes*

Yes

Choice Administrators

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: 1.0016-50 0.90

N/A

12 Months

No

Yes

2-14 15-50




HMO: N/APPO: Yes*

No*This does NOT include credit for the RX deductible


Yes—full-time student or disabled dependent information requested if child over age.

SPECIAL CONCERNS*

Infertility


PRESCRIPTIONS











101


ME

DI

CA

L

Hearing treatment

Are Hearing Aids covered?Call your Word & Brown representative




HMO/POS/PPO: Yes

HMO/POS/PPO: Yes

HMO

PPO

POS

Indemnity

HMO: Medical exams of the ear and audiometric exam to measure hearing

POS/PPO/Indemnity: Call your Word & Brown representative

Yes

Yes

Yes

Yes

100% after copay

Office visit copay

Office visit copay

$25 deductible then Maximum Allowable Charge

100% after copay

Office visit copay

Office visit copay

$10 deductible per visit then Maximum Allowable Charge

100% after copay

Office visit copay

Office visit copay


100% after copay

Office visit copay

Office visit copay


HMO: 50% for diagnosis and treatment of cause ofinfertility.

POS/PPO/Indemnity: Benefits vary by plan

Speech therapy HMO: Covered if medically necessary

PPO: Covered if medically necessary

POS: Covered if medically necessary

Indemnity: Covered if medically necessary

DIABETIC BENEFITS


102



Insulin

Needles & Syringes

Glucose Monitor


Insulin Pump


















No Use plan pharmacies(including affiliated)

HMO



POS



PPO



Indemnity

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

103

Administration

HMOSharp Health Plan4305 University AvenueSuite 200San Diego, CA 92105800-359-2002



Customer Service 800-359-2002

Bilingual Support 800-359-2002


Broker Licensing Paperwork Fax 619-228-2444



HMOSharp Health PlanP.O. Box 939036San Diego, CA 92193

Claims

ME

DI

CA

L

�PPO Counties

HMO & PPO Counties


PRODUCTS OFFERED PROVIDER INFORMATION

HMO/EPO PPO POS

104









Anytime—change is effective 1st of the following month

No

No

Yes

*See page 107 for details.

Sharp Health Plan

24 HOUR COVERAGE


Yes

Yes—if OB/GYN is listed as a PCP

Yes—for OB/GYN visits if OB/GYN is in same IPA as PCP.Sharp Rees-Sealy enrollees can self-refer to allergists, ENTS,OB/GYNs, ophthalmologists &podiatrists.

Yes—if available through medical group


SELECTION

NETWORKS

LIFE†

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

OPTIONAL BENEFITS†

GROUP SIZE


HSA-CompatiblePPO

HRA-CompatiblePPO

MRP-CompatiblePPO


Blue Plan 10/10/0Blue Plan 15/15/250Blue Plan 20/30/500Blue Plan 20/40/1000Blue Plan 30/40/1000

Blue Plan 30/40/750/dayBlue Plan 40/40/750/day

Gold Plan 10/10/0Gold Plan 15/15/250Gold Plan 20/30/500Gold Plan 20/40/1000Gold Plan 30/40/1000

Gold Plan 30/40/750/dayGold Plan 40/40/750/day

2-19

Not Available

Discount dental throughFirst Dental Health is free to all small group HMO

members

Available

Not Available

Available

Discounts Available

Discounts Available

Sharp Health Plan

SharpHealth

Plan 20-50

Not Available

Discount dental throughFirst Dental Health is free to all small group HMO

members

Available

Rider Available*

Available

Discounts Available

Discounts Available

HMO

DUAL OPTION (MIX AND MATCH)Boxes containing a “●” indicate that these coordinate plans offered by this carrier can be writtentogether to create a dual option package. Blank boxes indicate which plans cannot be writtentogether.

HSA Companion Plan40/2500/5000

N/A N/A

Sharp Health Plan

Companion Plan 120/500/80/50

Companion Plan 230/1000/80/50

PPO

*Sharp Gold Network is all Sharp Medical Groups excluding the independently contracted physicians

HMOSharp Health Plan

PPOFirst Health and Interplan

Blue Plan

10/10/0

Blue Plan

15/15/250

Blue Plan

20/30/500

Blue Plan

20/40/1000

Blue Plan

30/40/1000

Blue Plan

30/40/750

Blue Plan

40/40/750

Gold Plan

10/10/0

Gold Plan

15/15/250

Gold Plan

20/30/500

Gold Plan

20/40/1000

Gold Plan

30/40/1000

Gold Plan

30/40/750

Gold Plan

40/40/750

CompanionPlan 1

$20/80%/50%

CompanionPlan 2

$40/80%/50%

* Any groups with 6+ employees can choose a combination of one PPO and/or 1 HSA plan and any HMO plans.

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

● ● ● ● ● ● ● ● ● ● ● ● ● ● ●

†Assist America (worldwide emergency services coverage) free with all Sharp HMO plans

Blue Plan 10/10/0Blue Plan 15/15/250Blue Plan 20/30/500Blue Plan 20/40/1000Blue Plan 30/40/1000Blue Plan 30/40/750Blue Plan 40/40/750Gold Plan 10/10/0Gold Plan 15/15/250 Gold Plan 20/30/500Gold Plan 20/40/1000Gold Plan 30/40/1000Gold Plan 30/40/750 Gold Plan 40/40/750Companion Plan 1$20/80%/50%

Companion Plan 2$40/80%/50%

2-9 No10-15 Yes—minimum of 10 must enroll with

Sharp16-50 Yes–minimum of 10 or 50% (whichever

is greater) must enroll with Sharp



Union/Non-union?

Minimum group size

Does carrier underwrite and rate carve outgroups according to AB1672 guidelines?

105

GROUP Can be written with Kaiser?†

SIZE







Yes—if listed on employer's DE-6

Yes—1099 Employees are not defined as an eligibleemployee and therefore not protected by AB1672; however, Sharp Health Plan will allow 1099 employeesto enroll, subject to the guidelines listed in SpecialConsiderations section at right.

Yes—emergency services covered worldwide

HMO: No PPO: Yes

Not applicable

Employees must reside or work within the service area.

Guidelines for 1099 employee coverage:

• 1099 employees must appear on the prior carrier billing statement.

• An Employer may only add 1099 employees to their plan either at the initialenrollment or at renewaL

• 1099 employees must work full-time (minimum of 30 hours per week) on ayear-round basis or 20 hours per week if the group covers part-timeemployees.

• There must be an affiliation between the employer and the employee longenough for a Federal Tax return to be filed.

• The employer must agree to contribute the same amount towards thepremium as they would for an employee reported on a W-2.

• The employer must agree to offer coverage to all future 1099 employees.

• No more than 25% of the group may be 1099 employees.

• The 1099 employee verification form must be completed and submittedalong with the following documentation:

-- Letter from the employer requesting to cover 1099 employees. -- Copies of the Form 1040 Schedule C and Form 1099 Miscellaneous

for the prior year.

Yes—if approved by Sharp underwriting. A minimum of 5 must enroll. 100% participation andan Individual Health Questionnaire is mandatory. Call representative

Pre-approval required from Sharp. Call representative

Pre-approval required from Sharp. Call representative

5 enrolledPPO - Carve-outs down to 2 lives with minimum of 3HMO subscribers

No

2-9 No10-15 Yes—minimum of 10 must enroll with

Sharp16-50 Yes–minimum of 10 or 50% (whichever

is greater) must enroll with Sharp


Employees

For Dependents

% of Total Cost:



PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE


WRAP* REQUIREMENTS

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

◆◆ 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

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


N/A

N/A

Sharp Health Plan

Sharp Health Plan

Sharp Health Plan

Sharp HealthPlan

2-50

50


Min. # of employees

Max. # of employees


† SHARP WILL NOT PERMIT WRAP WITH CALIFORNIACHOICE®

Employees

Dependents

Employees

Dependents

◆◆ 100%

N/A

2-50

◆◆ 70% HMO Only◆◆ 75% HMO and PPO

N/ A

ME

DI

CA

L

Employer can choose between adefined amount ($100 minimum) or a percentage (50% minimum).

minimum of 2 eligible employees*

*AB1672 group of 2 with one waiver due to other group coverage

AFTERISSUEINITIAL

N/A

minimum of 2 eligible employees*

106












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




Payroll Records OK if no DE-6?






GROUP SIZE


RATING INFORMATION

2-50

Yes

No

Yes

No

No

No

Yes

No

No

No

No

No

No

No

Yes

1st of the month

N/A

1st of the month following date of hire; Max: 365 days

60 days of effective date

Use either 1 or 2 (Group must have a minimum of 2 subscribers)

Yes

Yes

No

Yes

Yes—annually at employer's election

Current Employees

TimelyAdd-ons*

6-24

Individual HealthQuestionnaire

Individual HealthQuestionnaire

Sharp Health Plan

Sharp Health Plan

FEES







2-5: Automatic 1.106+: .90 - 1.1

No

12 Months

No

No

RAF Increments (2-50 Lives)

Composite Rates


Apply Trend Factor?

Use Employee Zips?



25-50

GroupQuestionnaire

GroupQuestionnaire

N/A

N/A

N/A

Yes

Yes

Yes

Yes

Yes

HMO: Sharp Health PlanPPO: American AlternativeInsurance Corporation (AAIC)

Yes

No

* Groups of 2-5 receive an automatic 1.10 RAF — Individual Health Questionnaires not required


SPECIAL CONCERNS*

Hearing treatment Hearing exams by PCP covered as any illness to determine need for hearing correction


PRESCRIPTIONS











107

Are Hearing Aids covered?Not covered

ME

DI

CA

LYes—or member must pay non-formulary copay

YesCovered at double the retail copay

Yes

Yes

Yes—non-formulary copay applies

Sharp Health Plan

Sharp Health Plan

Sharp Health Plan

InfertilityCovered at 50%; see Member Handbook for details of covered expenses. If a 20+ group, optional riders available for ART (Assisted Reproductive Technologies)—call your representative for details

Speech therapyTreatment of acute conditions covered as any illness - (See Member Handbook for details)

HMO 100% after office 100% after office 100% after office 100% after officevisit copay visit copay visit copay visit copay

PPO $250 annual benefit in and out of network

after copay

100% after officevisit copay



DIABETIC BENEFITS


108





Insulin

Needles & Syringes

Glucose Monitor


Insulin Pump









Sharp Health Plan

Sharp Health Plan

Sharp Health Plan



Diabetic Supply Benefit





Some medicationsand/or dosages may require

prior authorization


HMO plans:


Some medicationsand/or dosages may require

prior authorization


PPO plans:



109

HMO/EPO Counties

PPO Counties

Both Plan Types��PPO Counties

HMO, POS & PPO Counties

CLAIMS ADDRESS INFO:

HMO ClaimsPacifiCare of CaliforniaP.O. Box 6006Cypress, CA 90630800-624-8822

PPO ClaimsPacifiCare of CaliforniaP.O. Box 6099Cypress, CA 90630866-316-9776

POS Out-of-Area ClaimsPacifiCare of CaliforniaP.O. Box 6019Cypress, CA 90630

★ Signature Value Advantage plans are only available in these eight counties:

Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego,San Francisco and Santa Clara.

ME

DI

CA

L

Colusa

CalaverasMarin

Monterey

Sacra-mento

Alameda

AlpineAmador

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

Member Support

Customer Service

Bilingual SupportGroup ServiceCall Center

Broker Service/Commissions(Small Group)

Adds/Terms

PacifiCare of California5701 Katella AvenueCypress, CA 90630-5028

800-624-8822 (HMO)800-913-9133 (POS)866-316-9776 (PPO)

Call Member Support(See above)

Call Member Support(See above)

(See addresses under map)

Administrator Claims

Fax 866-372-1316

800-591-9911

800-947-1672

HMO

IMPORTANT NOTICE: UnitedHealthcare will be eliminating the PacifiCare PPO and POS portfoliofrom the marketplace effective January 1, 2010. Affected customers will be offered comparableUnitedHealthcare options at their renewal on or after January 1, 2010.

LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

PRODUCTS OFFERED

OPTIONAL BENEFITS

GROUP SIZE


HMO/EPO PPO POS

110








Does carrier allow an OB/GYNto be Primary Care Physician?DUAL OPTION (MIX AND MATCH)

PacifiCare Choice Series: Groups enrolling 5–50 active employees may select up to four HMO, HMOAdvantage and/or PPO plans. HMO plans may not be offered alongside HMOAdvantage plans. Minimum participation requirement is 75%. Refer tounderwriting guidelines for product options available. If you need assistance,please contact your Word & Brown representative.

Available

Available

Not Available

PPO: Included; HMO/POS: Rider Available

PPO: Included; HMO/POS: Rider Available

Not Available

2-50

HMOPacifiCare HMOPacifiCare Signature Value Advantage(Limited network)

PPO

PacifiCare Life and Health PPO

Out of California PPONational network consisting of PL&Hproprietary network and PHCS

No, if legally exempt

No

Yes, if legally exempt

* Only available to out-of-state employees of a PacifiCare group.No Hawaii employees. Maximum percentages apply. Seebottom of page 111 for details.

** Only available on a standalone basis† Only available in eight counties: Kern, Los Angeles, Orange,

Riverside, San Bernardino, San Diego, San Francisco and SantaClara.

SignatureValue™ 10-30/100SignatureValue™ 15-30/250aSignatureValue™ 20-40/500d

SignatureValue™ 35/600dSignatureValue™ 10/500d

SignatureValue™ 20/1500dedSignatureValue™ Advantage 10/500d †

SignatureValue™ Advantage 20/1500ded†

SignatureValue™ Advantage 35/600d †

SignatureValue™ Advantage 40-60/2000dedSignatureValue™ 10-30/500dSignatureValue™ 15-30/300a

SignatureValue™ 20-40/1500dSignatureValue™ 10-30/100 Advantage

SignatureValue™ 10-30/500d AdvantageSignatureValue™ 15-30/300a Advantage

SignatureValue™ 20-40/1500d AdvantageSignatureValue™ 20-40/500d AdvantageSignatureValue™ 35-45/600d Advantage

HCP Network HMO 25-50/500 ded.HCP Network HMO 25-75/1500 ded.HCP Network HMO 25-75/500 ded.

HMO PPO

POS

▲= Triple Option Plan


24 HOUR COVERAGE


As often as necessary (submit changerequest on or before the 15th in orderto be effective the 1st of the followingmonth)

Yes

Yes—if listed as a PCP in the directory

HMO: Yes—for OB/GYN visits (OB/GYN must be in the same medical group/IPA asyour PCP)

POS: HMO (Tier 1): Yes—same as HMO above; PPO (Tier 2): No PCP selection required

PPO: Yes—no PCP selection required

Yes—if an Express Referrals™participating medical group. SeePacifiCare Provider Directory orwww.pacificare.com for list ofparticipating medical groups.

SignaturePOS™15/80-60 **


HRA-Compatible PPO

SELECTION

NETWORKS

SignatureOptionsTM 70-50/2000

MRP-Compatible PPOSignatureOptionsTM 10/90-70/250SignatureOptionsTM 15/90-50/250SignatureOptionsTM 20/80-60/250SignatureOptionsTM 30/70-50/250SignatureOptionsTM 35/80-60/500SignatureOptionsTM 35/50-50/1000SignatureOptionsTM 35/70-50/1000

SignatureOptionsTM 70-50/2000SignatureOptionsTM 70-50/3500


PacifiCare PPO and Indemnity products are available through UnitedHealthcare. For details, contact your UnitedHealthcare representative.





SignatureOptions™ 15/80-60SignatureOptions™ 20/90-50/250SignatureOptions™ 30/80-60/250SignatureOptions™ 30/80-60/500SignatureOptions™ 40/50-50/1000SignatureOptions™ 40/70-50/1000SignatureOptions™ 40/70-50/250SignatureOptions™ 70-50/2000SignatureOptions™ 70-50/3500

Employees

Dependents

Employees

Dependents

PARTICIPATION

EXCLUSIONS ALLOWED BY CARRIER:

Hourly/Salary?1) Groups excluding classes are subject to underwriting approval

and may be declined if they do not meet PacifiCare underwritingcriteria. Call your Word & Brown representative

2) Employer must provide a letter indicating why they want to offerone class of employees and not the other

3) No other carrier offered alongside4) The case is non-guarantee issue

Management/Non-management?1) Groups excluding classes are subject to underwriting approval




Union/Non-union?1) Groups excluding classes are subject to underwriting approval




Minimum group size2

Does carrier underwrite and rate carve out groups according to AB1672 guidelines?No

AFTERINITIAL ISSUE

1*

50

1*

50*AB1672 group of 2 with one waiver due to other group coverage

Min. # of employees

Max. # of employees









Employees

For Dependents

% of Total Cost:



Non-Contributory

GROUP SIZE


WRAP* REQUIREMENTS



111

ME

DI

CA

L

Contributory

50%

- 0 -

- 0 -

of average employee-only premium

◆◆75%

N/A

Standalone or Choice Option2-15

◆◆100%

N/A

◆◆60%

N/A

16-50

◆◆100%

N/A

◆◆75%

N/A

10-15

◆◆100%

N/A

Choice Series (Multi Choice)

◆◆ Those covered by another plan are NOT considered eligible in calculatingparticipation. In order to NOT be considered eligible, the other coveragemust be a group plan through their spouse or parent's employer,Champus, MediCal or Medicare (if no share-of-cost to individual). COBRAparticipants and employees in waiting period are not considered eligibleemployees. Therefore, they are not included when determining the totalgroup size.

1) Health statements are required for all employees 2-50. 2) Group must have Workers' Comp policy in force.3) Employee must work or reside within PacifiCare of California's

service area in order to enroll in a PacifiCare HMO or POS plan.4) A 2-life husband and wife group cannot be a sole proprietor

with both names on the business license. One must be a W-2 employee. Call your Word & Brown representative forsubmission requirements on husband and wife partnerships orcorporations.

5) Any group coming out of a current PacifiCare PEO will not be re-written as a new PacifiCare small group. Contact your Word & Brown representative for details regarding transferprocedures and rates.

2-50 No



◆◆60%

N/A

16-50

◆◆100%

N/A

Yes—if they receive a W-2 or are an owner/partner/officer

May be allowed on an exception. Prior approval fromPacifiCare underwriting required prior to submission. Call your Word & Brown representative

Emergency coverage only

Yes—on PPO, utilizing both PacifiCare's proprietary and PHCS'national networks.

No more than 25% outside a PacifiCare state.

POS or Choice Option:2-50 No

HMO, PPO or Multi Choice Option:2-9 No

10-15 Yes—with a staff model HMO only (i.e. Kaiser). Minimumof 10 (excluding COBRA) must enroll with PacifiCare

16-50 Yes—with one other HMO allowed & 60% of eligible employees must enroll with PacifiCare. For Multi Choice Option, 75% participation required and it must be a staff model HMO

Groups must have at least 10 enrolled employees with PacifiCare to be eligible tooffer another carrier (excluding allowable waivers).


2-50






Current Employees

TimelyAdd-ons












GROUP SIZE


RATING INFORMATION

112


1st of month only

N/A

0-6 months*

60 days prior to the requested effective date †

2-life group: separate apps**/3+: either 1 or 2

Yes

Yes

Not currently

Yes

Annually only

Health statements are required for all employees 2-50

*2-9 enrolling employees:only 1 waiting period allowed for all new hires

10-50 enrolling employees: may have 2 waiting periods based upon specific job classifications (e.g. management/non-management, salaried/hourly, etc.)

1 Group must submit letter on company letterhead that contains: 1) start date of business(minimum 45 days in business); 2) Tax ID number; 3) list of all current employees with hiredate and Social Security Number for each. Must also submit a summary page, a copy ofcurrent Business License, Business Tax Certificate or receipt of payment for CaliforniaBusiness License. If group comprised of all owner/partners with no DE-6, call yourrepresentative for submission details. Payroll records must meet requirements listed inPacifiCare Quick Reference Guide—call representative for details.

*If DE-6 from EDD, no cover page required but may be requested by PCUV if math does not balance. If DE-6 from ADP (payroll service) mustsubmit cover page or quarterly Tax Summary to confirm total employeecount.

** See Special Considerations sectionon page 111 for important information regarding 2-life husband and wifegroups

† Applications must be dated priorto or on the 1st day of the monthin which coverage becomeseffective or PacifiCare will roll thegroup

HMO: N/APPO & POS: Yes

HMO: N/APPO & POS: No

Yes—except as noted below*

Yes—if DE-6 not filed yet 1

No For PPO or Dental only

YesPacifiCare





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

Yes

No

Yes

No

No

No

Yes

No

No

No

No

No

No

No

No


DE-6 statement required?Payroll Records OK if no DE6?Is a Prior Booklet required?Is Prior Billing required?Must submit check with initial application?Check Made payable to:

RAF by Group Size

Composite Rates


Apply Trend Factor?

Use Employee Zips?

Full Medical 2-50

* Employees with health conditions that are named by the employer in theresponses must submit an Individual Health Statement

N/A

Contract states 6-month re-rating(in accordance with CA insurance code).However, in practice PacifiCare has lengthened this to 12-months

No

No



1) Less than 3 enrolled employees is 1.102) Groups of 3 enrolled employees 1.00-1.103) Groups of 4 enrolled employees .95-1.104) 5+ enrolled employees is .90-1.10


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

Are non-formulary drugs available?Yes—higher non-formulary copay applies. ForSignaturePOS™, both formulary and non-formulary are covered on in-network level only


Yes—2 retail copays




SPECIAL CONCERNS*


PRESCRIPTIONS




113

PRESCRIPTIONS

HMO & POS

PPO

Periodic Health Evaluations covered—100% after office visit copay (POS covered

in-network level 1 only)

Periodic Health Evaluations(age 19 & over) covered to

max. $400 per calendar year


(POS: level 1 only)

Covered throughage 18


(POS: level 1 only)

Covered


(POS: level 1 only)

Covered

Hearing treatmentHMO: Hearing screening exam by PCP or PCP

referred specialist covered at office visit copay for a specialist

POS: Covered in-network only as outlined above for HMO

PPO: Routine hearing screening to determine hearing loss covered under Periodic Health Evaluations

Note: If a company offers UnitedHealthcare’s PPOportfolio and the PacifiCare HMO portfolio, they willhave two different Rx systems.

Managed or Closed Formulary Plans: Yes—or member must pay the brand

formulary or brand non-formulary copayplus the difference between the genericprice and the brand price

Open Formulary Plans: Yes—or member must pay non-formulary copay

Yes—only for members with a three tier or buy-up Rxbenefit.

SignatureOptions™ 70-50/2000 and 70-50/3500 have a $250 separate annual Rx deductible combined for formulary and non-formulary drugs

SignatureOptions™ 70-50/2000 &SignatureOptions™ 70-50/3500

Deductible & Coinsuranceapplies




All other SignatureOptions™PPO plans:

100% after office visit copay.Deductible & coinsurance

applies to lab & x-ray








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Speech therapyHMO: Included in Outpatient Rehabilitation

Therapy. Benefit: 100% after office visit copay. (Limitations apply— see Evidence of Coverage)

POS: Covered in-network only as outlined above for HMO

PPO: Combined $2000 max. per calendar year for speech, physical and occupational rehabilitation services (Limitations apply—see Evidence of Coverage)

InfertilityHMO 20-40/500d: Not covered

HMO Value 40-60/2000ded: Not covered

HMO 35/600d: Not covered

Advtg 10/500d &Advtg 35/600d: Not covered

HMO 10-30/100& HMO 15-30/250a: 50% of cost copay for

covered benefits

POS: In-network level only - 50% of covered benefits

PPO: Max. $2000 while insured by PacifiCare





DIABETIC BENEFITS


114




Insulin

Needles & Syringes

Glucose Monitor


Insulin Pump









PacifiCare

HMO plans:*

POS plans:

PPO plans:






Usually Durable Medical Equipment Benefit—supplies containing insulinare covered under Prescription Drug Benefit

Medical Benefit Yes—pre-authorizationmay be required

Yes

Medical Benefit Yes—pre-authorizationmay be required

Yes

Medical Benefit Yes Yes

* With the SignatureValueTM, SignatureValueTM Advantage, and SignaturePOS plans, a separate copayment applies forinjectable drugs except when the negotiated rate is less than the copayment amount—then you will pay the negoti-ated rate. The copayment for SignatureValueTM Advantage 10/500d is $150 and the copayment for 35/600d is $100



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

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PPO Counties�


Plan may not be available in all zip codes within county. Check with your Word & Brown rep to confirm if coverage is available for your group location.

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Member Support Call number on ID card (or temporary ID printed after registration on myuhc.com)

Group ServiceCall Center 888-842-4571, press 2

Broker Service/Commissions 888-842-4571, press 1(Small Group) [email protected]

Adds/Terms Call your Word & Brownrepresentative

Account Executive Department 866-288-4993, prompt 1, 1

Fax 800-926-2951

5701 Katella AvenueCypress, CA 90630-5028800-858-9168Fax 800-926-2951

Administrator Claims

UnitedHealthcareP.O. Box 659426San Antonio, TX

78265-9426




LIFE

DENTAL

VISION

INFERTILITY

CHIROPRACTIC

ACUPUNCTURE

MASSAGE THERAPY

PRODUCTS OFFERED

OPTIONAL BENEFITS

GROUP SIZE


116








No, if legally exempt

No

Yes, if legally exempt

UnitedHealthcare Choice Plus Traditional w/ Deductible PPO 20/250/90% (C3-J)UnitedHealthcare Choice Plus Traditional w/ Deductible PPO 30/500/80% (C3-M)UnitedHealthcare Choice Plus Traditional w/ Deductible PPO 40/500/70% (C3-R)

UnitedHealthcare Choice Plus Balanced PPO 20/3000/90% (C3-I)UnitedHealthcare Choice Plus Balanced PPO 30/1000/80% (C3-K)UnitedHealthcare Choice Plus Balanced PPO 30/2500/80% (C3-L)UnitedHealthcare Choice Plus Balanced PPO 40/1000/70% (C3-P)UnitedHealthcare Choice Plus Balanced PPO 40/1500/70% (C3-Q)UnitedHealthcare Choice Plus Balanced PPO 40/1000/50% (C3-N)UnitedHealthcare Choice Plus Balanced PPO 40/2000/50% (C3-0)

UnitedHealthcare Choice Plus Balanced Value PPO 20/3000/90% (D6-L)UnitedHealthcare Choice Plus Balanced Value PPO 30/1000/80% (D6-M)UnitedHealthcare Choice Plus Balanced Value PPO 30/2500/80% (D6-N)UnitedHealthcare Choice Plus Balanced Value PPO 40/1000/70% (D6-Q)UnitedHealthcare Choice Plus Balanced Value PPO 40/1500/70% (D6-R)UnitedHealthcare Choice Plus Balanced Value PPO 40/1000/50% (D6-0)UnitedHealthcare Choice Plus Balanced Value PPO 40/2000/50% (D6-P)

UnitedHealthcare Non-Differential PPO 2000/80% (6H-F)

PPO


24 HOUR COVERAGE








SELECTION

NETWORKS

UnitedHealthcare Choice Plus Definity HSA 2000/100% (D6-K) UnitedHealthcare Choice Plus Definity HSA 1500/80% (C3-Z)

UnitedHealthcare Choice Plus Definity HSA (embedded) 2850/80% (D6-I)UnitedHealthcare Choice Plus Definity HSA 2850/80% (D6-J)

UnitedHealthcare Choice Plus Definity HSA (embedded) 3000/70% (C3-X)UnitedHealthcare Choice Plus Definity HSA 3500/70% (C3-Y)

HSA

UnitedHealthcare Choice Plus Definity HRA 2000/90% (C3-W)UnitedHealthcare Choice Plus Definity HRA 1500/80% (C3-U)UnitedHealthcare Choice Plus Definity HRA 2500/80% (C3-V)UnitedHealthcare Choice Plus Definity HRA 2000/70% (C3-S)UnitedHealthcare Choice Plus Definity HRA 3000/70% (C3-T)

HRA

Available

Available

Available

Available

Available

Available

Not Available

2-50

DUAL OPTION (MIX AND MATCH) UnitedHealthcare

UnitedHealthcare Multi-Choice package: Groups enrolling 5-50 active employeesmay select up to a total of 35 PacifiCare HMO and UnitedHealthcare PPO plans.HMO plans may not be offered alongside HMO Advantage plans. Minimumparticipation requirement is 75%. Refer to underwriting guidelines for productoptions available.

UnitedHealthcare

UnitedHealthcare


UnitedHealthcare

GROUPSIZE PPO or Indemnity

Employees

Dependents

Employees

Dependents

EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Available for groups with 2-50 eligible employees. All included classesmust meet participation guidelines for the class. The employer mustsubmit a signed, dated letter on company letterhead confirming the classdescription and verifying that no other group medical coverage is beingoffered to the otherwise eligible employees excluded by the classdescription

Management/Non-management?Available for groups with 2-50 eligible employees. All included classesmust meet participation guidelines for the class. The employer mustsubmit a signed, dated letter on company letterhead confirming the classdescription and verifying that no other group medical coverage is beingoffered to the otherwise eligible employees excluded by the classdescription

Union/Non-union?Available for groups with 2-50 eligible employees. All included classesmust meet participation guidelines for the class. The employer mustsubmit a signed, dated letter on company letterhead confirming the classdescription and verifying that no other group medical coverage is beingoffered to the otherwise eligible employees excluded by the classdescription. Note: Union/Non-union requires a copy of the union bill.

Minimum group size2

Does carrier underwrite and rate carve out groups according to AB1672 guidelines?No—These groups are non GI



Employees

For Dependents

% of Total Cost:



PARTICIPATION

Min. # of employees

Max. # of employees

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE

AFTERINITIAL ISSUE

CARVE OUTS*

WRAP* REQUIREMENTS


117



Are Commission-Only employees allowed?Call your Word & Brown representative

Are 1099 employees allowed?Yes—maximum of 25% of the enrolled may be 1099contractors, and the independent contractors paid by1099 form is required

Are employees covered if traveling out of USA?Emergency coverage only

Is coverage available for out-of-state employees?No more than 25% of the group may be located inVermont or Washington.

Max. % of employees residing out-of-stateallowedThe group will be rated in the state with 51% of theeligible employees. If there is not 51% of the eligibleemployees in any state, special guidelines apply todetermine base location. Contact your Word & Brownrepresentative

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2-50

2-50 UnitedHealthcare PremierSource™: No

10-15 Standalone (one UnitedHealthcare plan): Yes—minimum 75% of eligible employees must enroll with UnitedHealthcare*


10-50 UnitedHealthcare Multi-Choice package: Yes—minimum 75% of eligible employees must enroll with UnitedHealthcare*

1) Health statements are required for all employees 2-50, includingCOBRA or Cal-COBRA continuees

2) Group must have Workers' Comp policy in force.3) A 2-life husband and wife group cannot be a sole proprietor with both

names on the business license or Schedule C. Husband/wife groupsmust provide separate tax or QWR documentation showing they arean owner or full-time employee. Call your Word & Brownrepresentative for submission requirements on husband and wifepartnerships or corporations.

4) Business must be located in UnitedHealthcare’s licensed service areato be eligible for the products licensed in that area.

5) Proof of ownership documentation is required for all groups applyingfor medical coverage with fewer than 6 enrolling employees or anysize “owner only” groups.

2 2

50 50

50%

- 0 -

- 0 -

◆◆75%

N/A

2-15

◆◆100%

N/A

◆◆60%

N/A

16-50

◆◆100%

N/A

◆◆ Those covered by another plan are NOT considered eligible in calculatingparticipation. In order to NOT be considered eligible, the other coveragemust be a group plan through their spouse or parent's employer,Champus, MediCal or Medicare (if no share-of-cost to individual). COBRAparticipants and employees in waiting period are not considered eligibleemployees. Therefore, they are not included when determining the totalgroup size.

UnitedHealthcare

UnitedHealthcare

UnitedHealthcare

GROUPSIZE HMO, POS or EPO10-50 UnitedHealthcare PremierSource™: Yes—staff model

HMO only. 75% of eligible employees must enroll in UnitedHealthcare and the staff model HMO with a minimum of 5 active employees enrolling in the PremierSource portfolio (those waiving for a staff model HMO do not count toward participation.)



10-50 UnitedHealthcare Multi-Choice package: Yes—minimum 75% of eligible employees must enroll with UnitedHealthcare*

* The Standalone (one UnitedHealthcare plan) and UnitedHealthcare Multi-Choice package entries that appear in the PPO/Indemnity wraprequirement section above also apply to HMO, POS or EPO plans.


Current Employees

TimelyAdd-ons

RAF by Group Size

Composite Rates

Rate Guarantee*

Apply Trend Factor?

Use Employee Zips?




















FEES






GROUP SIZE

RATING INFORMATION

118





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

Yes*

No

Yes (including all pages)

Yes

UnitedHealthcare

N/A


N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

N/A

Health Statements are required forall employees 2-50



No

12 Months

No

No

1st (or 15th of the month for UnitedHealthcare standalone only)


minimum: 0 maximum: 180 (1st of the month following)

90 days prior to effective date; however for backdating, alldocuments must be received, signed and dated by the 5th ofthe month in order to backdate coverage to the 1st of the month

2 life group: separate apps / 3+ group: either 1 or 2 but no double coverage allowed

Yes

Periodically

Yes

1) Less than 3 enrolled employees is 1.102) Groups of 3 enrolled employees 1.00-1.103) Groups of 4 enrolled employees .95-1.104) 5+ enrolled employees is .90-1.10

UnitedHealthcare

UnitedHealthcare

Yes—only if the company has notbeen in business long enough tohave filed a DE-6.†

Yes, month prior to renewal—plan changes (Benefit Modifications) aresubject to Underwriting review and approval at open enrollment

* If DE-6 reflects more than a 50% change in census, a current payroll will also be required† Husband/wife groups or groups comprised of family members must always provide a Quarterly Wage Report (DE-6)

Health Statements are required forall employees 2-50

Yes—if UnitedHealthcare PremierSource™ is written with a staff model HMO,the staff model HMO applications must be submitted in lieu of waivers

SPECIAL CONCERNS*


PRESCRIPTIONS





FORMULARY VS. NON-FORMULARYDoes carrier use Rx formulary?No

Are non-formulary drugs available?UnitedHealthcare’s Rx portfolio does not base tiers on generic, brand, formulary and non-formulary.UnitedHealthcare products have a three tier system in small group that is drug specific. The member would need to refer to drug list to determine which tier the drug falls into.

If a company offers UnitedHealthcare’s PPO portfolio andthe PacifiCare HMO portfolio, they will have two differentRx systems.

MAIL ORDER - 90 DAY SUPPLYYes—2.5 X copay



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

119


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All Traditionaland BalancedChoice Plans

Covered at 100% afteroffice visit copay.Deductible and

coinsurance applies to lab and x-ray







Yes

Yes

UnitedHealthcare

UnitedHealthcare

UnitedHealthcare

Hearing treatmentMaximum 30 visits of post-cochlear implant auraltherapy. Pre-service notification is required. Copaymentvaries by plan—see Certificate of Coverage for details


Speech therapySpeech therapy is not covered except as required fortreatment of a speech impediment or speechdysfunction that results from injury, stroke, cancer,congenital anomaly or autism spectrum disorders.Maximum 20 visits of speech therapy. Pre-servicenotification is required. Copayment varies by plan—see Certificate of Coverage for details

InfertilityAvailable

Services to treat or correct underlying causes ofinfertility are covered. Benefits are limited to $2,000 percovered person during the entire period of time he orshe is enrolled for coverage under the policy. Pre-service notification is required. See Certificate ofCoverage for details.

Health services and associated expenses for infertilitytreatments, including assisted reproductive technology,regardless of the reason for the treatment, are notcovered.

DIABETIC BENEFITS

These services may change at any time without notice. Please contact your Word & Brown rep for specific inquiries on listed services

120



Insulin

Needles & Syringes

Glucose Monitor


Insulin Pump









UnitedHealthcare

UnitedHealthcare



Durable Medical Equipment Benefit*


Durable Medical Equipment Benefit*

Usually Durable Medical Equipment Benefit*—supplies containing insulinare covered under Prescription Drug Benefit

*Pre-service notification is required for Durable Medical Equipment and diabetes equipment in excess of $1,000

All Plans Call your Word & Brown representative



121


CONSUMERDIRECTED

PLANS

$4,000

$4,500

Health Plan Plan Name Co-pay/Co-insurance

Deductible Rx Coverage*

Small Group Plans

Anthem BlueCross

Blue Shield

Shield Savings 2250/4500

Shield Savings 2500

✓✓✓

✓

✓✓

Ded / 80%

Ded / 80%

Ded / $10, $30, $50

Ded / $10, $30, $50

Ded / 80%

Ded / 80%

Lumenos HSA 2500 80/50 Ded / 80% Ded / $10, $30, $50 Ded / 80%$2,500

$2,250

$2,000 Shield Savings 2000/4000 ✓Ded / 100% Ded / 100% Ded / 100%$2,000

$2,500

$5,000

High Deductible EPO ✓✓✓Ded / 80% Ded / $10, $25, 30% Ded / 80%$2,000

Lumenos HSA 1500 80/50 Ded / 80% Ded / $10, $30, $50 Ded / 80%$1,500

$3,100

$3,000

✓Lumenos HSA 2000 100/70 Ded / 100% Ded / 100% Ded / 100%$2,000 $2,000

✓Lumenos HSA 3500 80/50 Ded / 80% Ded / $10, $30, $50 Ded / 80%$3,500 $5,000

✓Lumenos HSA 3000 100/70 Ded / 100% Ded / 100% Ded / 100%$3,000 $3,000

PPO 2400 Ded / $35 Ded / $10, $25, 20% Ded / 80%$2,400

PPO 3500 Ded / $35 Ded / $10, $25, 30% Ded / 100%$3,500

$3,600


$4,000

Shield Savings 1800/3600 ✓Ded / 100% Ded / 100% Ded / 100%$1,800 $1,800

Shield Savings 3000/6000 ✓Ded / 100% Ded / 100% Ded / 100%$3,000 $3,000

Shield Savings 4800 ✓Ded / 100% Ded / 100% Ded / 100%$4,800 $4,800

$5,600

$4,500

HSA California

HMO HSA 2200

HMO HSA 2600

✓✓

Ded / $20

Ded / $30

Ded / $10, $20

Ded / $10, $30

Ded / 75%

Ded / 70%

$2,200

$2,600

HMO HSA 1800

✓

Ded / 100% Ded / 100% Ded / 100%$1,800 $1,800

HMO HSA 2800B

✓

Ded / $40 Ded / $10, $30, $50 Ded / $500 per day$2,800 $4,000

HSA 2500

✓

Ded / $25 Ded / $15, $30, $50 $250 / Ded / 70%$2,500 $5,000

HSA 3500

✓

Ded / $35 Ded / $15, $30, $50 $250 / Ded / 70%$3,500 $5,000

HSA 4500

✓

Ded / $45 Ded / $15, $30, $50 $250 / Ded / 60%$4,500 $5,600

✓

MC HDHP $3,000 80/50 ✓Ded / 80% Ded / $20, $40, $70 Ded / 80%$3,000 $4,500

Aetna

Hospital withHRA

Max Out Of Pocket

withHSA

Carrier-approved for sale

MC HDHP $2,300 80/50 ✓Ded / 80% Ded / $20, $40, $70 Ded / 80%$2,300 $4,000

MC HDHP $3,000 100/50

✓Ded / 100% Ded / $20, $40, $70 Ded / 100%$3,000 $4,000

MC HDHP $3,300 80/50

✓

HMO Ded $1,000 ✓$40 Ded / $20, $40, $60 Ded / 70%$1,000 $3,500

Ded / 80% Ded / $20, $40, $70 Ded / 80%$3,300 $5,000

✓

✓

Protect HSA 2850

CaliforniaChoice HSA 1500***

Ded / 70%

Ded / 80%

Ded / 70% Ded / 70%

Ded / 80%Ded / $15

$2,850

$1,500

✓✓✓✓

✓

$5,500

✓CalCPA Protect HSA 1500 Ded / 70% Ded / 70% Ded / 70%$1,500 $4,500

✓

Health Net

Value HSA 1500 Ded / $10 Ded / $10, $25, $50 Ded / 80%$1,500 $2,500

✓Value HSA 2500 Ded / $20 Ded / $15, $30, $50 $250 / Ded / 80%$2,500 $3,500

✓HRA 3000 Ded / 80% Ded / $10, $25, $50 Ded / 80%$3,000 $4,000

✓HRA 5000 Ded / 80% Ded / $10, $25, $50 Ded / 80%$5,000 $6,000

✓✓

Value HSA 3500

Value HSA 4500

Ded / $30

Ded / $40

Ded / $15, $30, $50

Ded / $15, $30, $50

$250 / Ded / 70%

$500 / Ded / 50%

$3,500

$4,500

$4,500

$5,000

Options PPO 3000 HSA

Options PPO 4000 HSA

Ded / $25

Ded / $35

Ded / $15, $30, $50

Ded / $15, $30, $50

$250 / Ded / 70%

$250 / Ded / 60%

$3,000

$4,000

$4,000

$5,000

Standard HSA 2000 Ded / 100% Ded / 100% Ded / 100%$2,000 $2,000



$2,800

✓HSA 2400*** Ded / 80% Ded / $15 Ded / 80%$2,400 $3,200

KaiserPermanente

✓✓

$30 / $1,500 Ded Plan w/HRA

$30 / $2,500 Ded Plan w/HRA

Ded / $30

Ded / $30

$10, $250 Rx BrandDed / $35, NA

$10, $250 Rx BrandDed / $35, NA

Ded / 80%

Ded / 80%

$1,500

$2,500

$3,000

$5,000

✓

HSA $0 / $1,500 Ded / 100% Ded / 100% Ded / 100%$1,500 $1,500

✓

HSA $0 / $2,200 Ded / 100% Ded / 100% Ded / 100%$2,200 $2,200

✓

HSA $0 / $2,700 Ded / 100% Ded / 100% Ded / 100%$2,700 $2,700

HSA $30 / $2,700 Ded / $30 Ded / $10, $35, NA Ded / 70%$2,700 $5,250

HSA 2400*** Ded / $30 Ded / $10, $30, NA Ded / 80%$2,400 $3,200

KaiserPermanenteChoice Solution

HSA 1400*** Ded / 100% Ded / 100% Ded / 100%$1,400 $1,400

HSA 2200*** Ded / $40 Ded / $15, $35, NA Ded / 70%$2,200 $4,000

✓✓

✓

✓Protect HSA 2500 Ded / 100% Ded / 100% Ded / 100%$2,500 $2,500


✓HSA PPO $40 / $2,500 Ded / $40 Ded / $15, $35, NA Ded / 70%$2,500 $5,000

✓Spectrum PPO Plan 3000 HRA Ded / 80% Ded / 80%Ded / $15, $30, $15$3,000 $6,000

✓

Consumer Directed Health Plans (CDHP)(November 2009)

123

Northern California 800.255.9673 ■ Inland Empire 877.225.0988 ■ Los Angeles 800.560.5614 ■ Orange 800.869.6989 ■ San Diego 800.397.3381

wordandbrown.com(Continued on following page)

124

Consumer Directed Health Plans (CDHP)

Word & Brown offers more to California’s brokerthan any other General Agency.

With Consumer Directed Health Plans, employers reduce monthlypremium and employees increase control over how their healthcaredollars are spent. Word & Brown can provide you with qualityinformation to help make decisions that are right for your client’sbudgets and needs.

Word & Brown Consumer Directed Health Plan Reference Tool – Answers your questions about HRAs, HSAs,FSAs and lists many of the expenses that typically qualify under these plans.

Tools you should be using today –

What Expenses Typically Qualify* Under An HRA, HSA, or FSA?HRAs and Health FSAs are subject to Code Section 105 generally; therefore, only expenses that qualify as medical care

under Code Section 213(d) are eligible for reimbursement, subject to some additional restrictions:• In accordance with Code Section 106, HRAs cannot reimburse expenses for qualified long term care services• In accordance with Code Section 106 and 125, Health FSAs cannot reimburse expenses for qualified long term

care services and/or insurance premiumsHSAs are subject to Code Section 223; therefore, only expenses that qualify as “medical care” under Code Section 213(d)

are eligible for tax free reimbursement except as otherwise limited by Code Section 223:• No insurance premiums except for long term care premiums, COBRA premiums, health coverage received whilereceiving unemployment compensation, and any deductible health insurance coverage for individuals who areage 65 or older, other than Medicare Supplemental Policies.

Medical Expenses:

Fees paid to the following providers for treatment of a specific disease:

• Acupuncture• Ambulance hire• Artificial limbs and teeth• Automobile modifications (handcontrols, special equipment, mechanicallifts if for handicapped persons)• Braille books & magazines• Contact lenses & solutions• Crutches/slings

• Doctor copays• Examination, physical• Eye examination

• Eyeglasses• Hearing devices• Hospital bills for medical care• Iron lungs, operating cost• Laetrile, when prescribed by doctor• Laser eye surgery• Lip reading lessons for the hearing impaired• Eligible over-the-counter

(OTC) medications*• Nursing care• Obstetrical expenses

• Operation• Oxygen equipment• Prescription drugs for medical care• Rental of medical or healing equipment(requires doctor’s note)• Seeing-eye dogs• Telephones for the hearing impaired• Transportation expense relative to illness(including doctor’s office)• X-Rays

• Chiropodist (expense)• Chiropractor• Clinic• Dentist• Doctor• Gynecologist• Hospital• Laboratory• Midwife• Nurse

• Obstetrician• Oculist• Ophthalmologist• Optician• Optometrist• Oral Surgeon• Osteopath• Pediatrician• Physician• Physiotherapist

• Podiatrist• Practical nurse• Psychiatrist• Psychoanalyst• Psychologist• Psychopathologist• Sanitarium• Specialist• Surgeon

Common expenses that are not eligible for reimbursement include: Cosmetic surgery for non-medical reasons (including liposuction, hair transplants

and electrolysis), weight loss programs (unless physician prescribed for treatment of a specific illness including obesity) and orthodontia services not

received during the plan year.FSA expenses must be incurred (i.e. services rendered) during the plan year.Funds can be withdrawn from an HSA Account for other purposes; however, the withdrawal amount will be subject to taxes and penalties. Please

consult your tax advisor.*The information in this document represents a summary of information only and does not constitute a guarantee of any benefit nor limit CONEXIS’

ability to require additional substantiation of a claim. Please refer to the plan summary that your Health Plan will provide for complete details on

the plan’s benefits, limitations and exclusions for your selected plan. For details concerning your rights and responsibilities with respect to your HSA

(including information concerning the terms of eligibility, qualifying High Deductible Health Plan, contributions to the HSA, and distributions from the

HSA), please refer to your HSA Custodial Agreement. OTC list available on request.

Qualified expenses must be for out-of-pocket medical care for the diagnosis, cure, mitigation, treatment or prevention of

disease, or for the purpose of affecting any structure or function of the body.


www.wordandbrown.comWB7108B.7.09

Employer funded medical expense

reimbursement plan for qualifying

medical expenses

Employer and/or Employee funded

account in the Employee’s name

(eligible individual) for current and

future medical expenses – requires a

High-deductible Health Plan and a

qualified trustee or custodian

Definition

Employee and/or employer

funded account for qualifying

medical expenses

Any Size Group

(Only common-law employees can

participate on a tax free basis.)

Any Size Employer

(Only eligible individuals can

establish an HSA).

Qualifications

Any Size Group

(Only common-law employees

can participate.)

Contributions are Tax Deductible when paid to

the participant to reimburse an expense

Contributions are Tax Deductible in the

year the contribution is made

Employer Tax Savings

Contributions are Tax Deductible when

paid to the participant to reimburse an

expense. As a result of salary reductions,

lower adjusted Employee income

reduces Employer matching FICA

& Federal Unemployment

An HRA is not subject to a minimum

deductible. An HRA may be offered in

conjunction with high deductible health

plan; however, deductible amount

established by employer.

$1,200 min (single)

$2,400 min (family)

Deductibles(2010)

A health FSA is not subject to a minimum

deductible. A health FSA may be offered in

conjunction with a high deductible health

plan; however, the deductible amount is

established by Employer.

Employer Sets Funding Levels

Maximum Out-of-Pocket

(2010)

Employer Sets Funding Levels

Employer

Employer, Employee, and for any

other Individuals

Source of Funding

Employer & Employee

Employer (unless benefits paid

from a trust)

Employee (eligible individual name on

the established trust account)

Who Owns

Unused Funds?

If funds attributable to employee

pre-tax salary reductions, the plan owns

(if an ERISA plan)

Can be offered alone or in conjunction

with a major medical plan.

Allows otherwise unreimbursed Code

213(d) medical expenses including health

insurance premiums. May not reimburse

expenses for qualified long term care

services. Employer may restrict scope of

reimbursements by plan design

(many plans limit reimbursement to

deductibles, co-payments, coinsurance).

If participant also has an HSA, the HRA

must be limited to the following: qualified

dental expenses, vision expenses, expenses

constituting preventive care, Premiums,

“suspended HRA”, and retiree only HRA.

Can only be established by those who

have qualifying high deductible health

plan coverage (deductible must meet

statutory limit) and no disqualifying non-

high deductible health plan coverage.

Employees who are entitled to Medicare

cannot establish or contribute to an HSA.

Allows otherwise unreimbursed medical

Code Section 213(d) expenses excluding

most premiums. An employer cannot

restrict the scope of HSA distributions

except for expenses paid with an

electronic payment card so long as account

beneficiary has other means to obtain

funds from HSA. Qualified expenses must

be incurred after the HSA is established.Allowable Expenses

& Plan Restrictions

Can be offered alone or in conjunction

with a major medical plan.

Allows otherwise unreimbursed Code

213(d) medical expense excluding

premiums and qualified long term

care services.

Employer may restrict scope of

reimbursements by plan design.

If participant also has an HSA, the FSA

must be limited to the following:

qualified dental expenses, vision

expenses, and expenses constituting

preventive care.

No (however, it may have a

post-termination spend-down feature.)

Yes – funds belong to the Employee

(eligible individual)

Is Fund Portable?

No

Yes

Yes

Prescription Co-pay

Yes

CONEXIS

Insurance Co, Bank, TPA

Administration

CONEXIS

Yes, if Employer specifies

Yes

Do Funds Rollover?

No* – however, an employer may establish a grace

period that follows the end of the plan year during

which unused amounts allocated to the FSA may

be used to reimburse eligible expenses incurred

during the grace period. The grace period may

not exceed two months and fifteen days.

Not required to prefund – uniform

coverage rule does not apply

Funds must be present before withdrawal

is made. Employer may contribute to

HSA periodically or all at once.

Funding Requirement

Uniform coverage rule applies – claims

must be paid without regard to

amount contributed

No

Taxable and Subject to 10% Penalty

(no penalty if age 65 or older or

disabled as defined by Code Section 72)

Non-medical Expense

Withdrawals

No

Reimbursements for

eligible expenses are excluded

from income

Contributions can be Pre-Tax or are Tax

Deductible on the Employee’s personal

tax return. Funds earn interest tax-free.

Reimbursements for qualified medical

expenses are excluded from income.

Employee may withdraw funds for

non-medical expenses subject to

income and excise tax.

Employee Tax Savings

Contributions are made Pre-Tax.

Reimbursements for eligible expenses

are excluded from income.

The information in this document represents a summary of the information only as of the date referenced below and does not constitute a guarantee of any benefit nor limit CONEXIS’ ability to require

additional substantiation of a claim. Refer to the published IRS documents for specifics. Health FSAs and HRAs are covered under IRS Section 105 and 106. Health FSAs are subject to additional rules set

forth in the regulations under IRS Code Section 125. HRAs are subject to additional rules set forth in Notice 2002-45 and Rev. Rul. 2002-41. HSAs were established under the Medicare Reform Package,

covered under IRS Code Section 223.

* As part of the Tax Relief and Health Care Act of 2006, HSAs can now be funded with a one-time tax free rollover from an existing FSA or HRA (a "Qualified HSA Distribution") provided certain conditions are satisfied

(this provision is effective upon enactment but expires January 1, 2012).

**Maximum contribution requires either full year eligibility or initial eligibility as of 12/01 and continuation of eligibility throughout the following year.

No – however, an employer may

establish annual plan limits.

Maximum Statutory

Contribution**

(2010)

No – however, an employer may


Northern California 800.255.9673 ■ Inland Empire 877.225.0988 ■ Los Angeles 800.560.5614 ■ Orange 800.869.6989 ■ San Diego 800.397.3381www.wordandbrown.com

WB7108B.7.09

$5,950 min (single)

$11,900 min (family)

$3,050 max (single)

$6,150 max (family)

$1,000 max (catch up contribution

for individuals age 55 or over)

HRA

Health Reimbursement Arrangement

HSAHealth Savings Account

FSAFlexible Spending Account

Health Plan Plan Name Deductible Rx Coverage*

Anthem Blue Cross PPO 3500 (HSA)

Blue Shield Shield Spectrum PPOSavings Plan 1800

✓

✓

✓✓

✓

Ded / $35

Ded / 100%

Ded / $10, $30, 50%

Ded / $10, $30, 50%

Ded / 70%

Ded / 100%

$1,800

$3,500

Hospital Max Out Of Pocket

Individual and Family Plans

Health NetFarm Bureau

CFB Saver ll 1800 HSA Ded / 100% Ded / 100% Ded / 100%$1,800



$5,600

Shield Spectrum PPOSavings Plan 5200

✓Ded / 100% Ded / 100% Ded / 100%$5,200 $5,200

Shield Spectrum PPOSavings Plan 4000

✓Ded / 100% Ded / 100% Ded / 100%$4,000 $4,000

$5,000

Health Net Optimum AdvantageHSA 2500

✓Ded / 100% Ded / 100% Ded / 100%$2,500 $2,500

Optimum AdvantageHSA 4500 ✓Ded / 100% Ded / 100% Ded / 100%$4,500 $4,500

N/A

N/A

N/A

Co-pay /Co-insurance

✓✓

HSA 1500 Ded / 100% Ded / 100% Ded / 100%$1,500

HSA 2700 Ded / 100% Ded / 100% Ded / 100%$2,700

$1,500

$2,700

✓HSA 5000 Ded / 100% Ded / 100% Ded / 100%$5,000 $5,000

PacifiCare


✓CFB Saver ll 3800 HSA Ded / 100% Ded / 100% Ded / 100%$3,800 N/A

Aetna HSA 3000 ✓Ded / 100% Ded / 100% Ded / 100%$3,000 $3,000

HSA 5000 ✓Ded / 100% Ded / 100% Ded / 100%$5,000 $5,000

✓Shield Spectrum PPOSavings Plan 2400 Ded / $35 Ded / $10, $30, 50% Ded / 70%$2,400 $4,000

✓Shield Spectrum PPOSavings Plan 3500 Ded / 100% Ded / $10, $35, $50 Ded / 100%$3,500 $5,000

✓✓✓

✓✓

UHC/PacifiCare

Definity HRA 2000/90%

Definity HSA 1500/80%

Ded / 90%

Ded / 80%

$10/$35, $60 after$250 Rx Ded

Ded / $10, $30, $50

Ded / 90%

Ded / 80%

$2,000

$1,500

$5,000

$3,000


Definity HSA 2850/80% –Embedded

Ded / 100%

Ded / 80%

Ded / $10, $30, $50

Ded / $10, $30, $50

Ded / 100%

Ded / 80%

$2,000

$2,850

$4,000

$3,500


Ded / 80%

Ded / 70%

Ded / $10, $30, $50

Ded / $10, $30, $50

Ded / 80%

Ded / 70%

$2,850

$3,000

$3,500

$5,000

withHRA

withHSA

Health Plan Plan Name Co-pay/Co-insurance

Deductible Rx Coverage*

Small Group Plans

Hospital withHRA

Max Out Of Pocket

withHSA


✓Definity HSA 3500/70% Ded / 70% Ded / $10, $30, $50 Ded / 70%$3,500 $5,000

Definity HSA 2850/80% –Non-Embedded

✓

Definity HRA 2000/70% Ded / 70%$10/$35, $60 after

$250 Rx Ded Ded / 70%$2,000 $5,000 ✓

Definity HRA 1500/80% Ded / 80% $10/$35, $60 after$250 Rx Ded Ded / 80%$1,500 $6,000 ✓

Definity HRA 2500/80% Ded / 80%$10/$35, $60 after

$250 Rx Ded Ded / 80%$2,500 $6,000 ✓

Definity HRA 3000/70% Ded / 70% $10/$35, $60 after$250 Rx Ded Ded / 70%$3,000 $6,000 ✓

* Generic Formulary, Brand Formulary, Brand Non-Formulary.** Group may receive a self funding factor load.

*** HSA - Qualified High Deductible Health Plan.† Maximum 3 doctor visits per member per year.

This summary is for general comparison purposes only. Please refer to the Evidence of Coverage orCertificate of Insurance for a detailed description of coverage benefits and limitations.

125



wordandbrown.com

Employer funded medical expensereimbursement plan for qualifying

medical expenses

Employer and/or Employee fundedaccount in the Employee’s name

(eligible individual) for current and future medical expenses – requires aHigh-deductible Health Plan and a

qualified trustee or custodian

DefinitionEmployee and/or employer

funded account for qualifying medical expenses

Any Size Group (Only common-law employees can

participate on a tax free basis.)

Any Size Employer(Only eligible individuals can

establish an HSA).Qualifications

Any Size Group(Only common-law employees

can participate.)

Contributions are Tax Deductible when paid tothe participant to reimburse an expense

Contributions are Tax Deductible in theyear the contribution is madeEmployer Tax Savings

Contributions are Tax Deductible whenpaid to the participant to reimburse anexpense. As a result of salary reductions,

lower adjusted Employee income reduces Employer matching FICA

& Federal Unemployment

An HRA is not subject to a minimum deductible. An HRA may be offered in

conjunction with high deductible healthplan; however, deductible amount

established by employer.

$1,200 min (single)$2,400 min (family)

Deductibles(2010)

A health FSA is not subject to a minimumdeductible. A health FSA may be offered inconjunction with a high deductible healthplan; however, the deductible amount is

established by Employer.

Employer Sets Funding LevelsMaximum Out-of-Pocket

(2010) Employer Sets Funding Levels

Employer Employer, Employee, and for any

other IndividualsSource of Funding Employer & Employee

Employer (unless benefits paid from a trust)

Employee (eligible individual name onthe established trust account)

Who Owns Unused Funds?

If funds attributable to employee pre-tax salary reductions, the plan owns

(if an ERISA plan)

Can be offered alone or in conjunctionwith a major medical plan.

Allows otherwise unreimbursed Code213(d) medical expenses including healthinsurance premiums. May not reimburse

expenses for qualified long term careservices. Employer may restrict scope of

reimbursements by plan design (many plans limit reimbursement to

deductibles, co-payments, coinsurance).

If participant also has an HSA, the HRAmust be limited to the following: qualifieddental expenses, vision expenses, expenses

constituting preventive care, Premiums,“suspended HRA”, and retiree only HRA.

Can only be established by those whohave qualifying high deductible healthplan coverage (deductible must meet

statutory limit) and no disqualifying non-high deductible health plan coverage.

Employees who are entitled to Medicarecannot establish or contribute to an HSA.

Allows otherwise unreimbursed medicalCode Section 213(d) expenses excluding

most premiums. An employer cannotrestrict the scope of HSA distributions

except for expenses paid with anelectronic payment card so long as account

beneficiary has other means to obtainfunds from HSA. Qualified expenses mustbe incurred after the HSA is established.

Allowable Expenses & Plan Restrictions

Can be offered alone or in conjunctionwith a major medical plan.

Allows otherwise unreimbursed Code213(d) medical expense excludingpremiums and qualified long term

care services.

Employer may restrict scope ofreimbursements by plan design.

If participant also has an HSA, the FSA must be limited to the following:qualified dental expenses, vision

expenses, and expenses constitutingpreventive care.

No (however, it may have a post-termination spend-down feature.)

Yes – funds belong to the Employee(eligible individual)Is Fund Portable? No

Yes YesPrescription Co-pay Yes

CONEXIS Insurance Co, Bank, TPAAdministration CONEXIS

Yes, if Employer specifies YesDo Funds Rollover?

No* – however, an employer may establish a graceperiod that follows the end of the plan year duringwhich unused amounts allocated to the FSA maybe used to reimburse eligible expenses incurredduring the grace period. The grace period may

not exceed two months and fifteen days.

Not required to prefund – uniformcoverage rule does not apply

Funds must be present before withdrawal is made. Employer may contribute to

HSA periodically or all at once.Funding Requirement

Uniform coverage rule applies – claims must be paid without regard to

amount contributed

NoTaxable and Subject to 10% Penalty

(no penalty if age 65 or older or disabled as defined by Code Section 72)

Non-medical ExpenseWithdrawals

No

Reimbursements for eligible expenses are excluded

from income

Contributions can be Pre-Tax or are TaxDeductible on the Employee’s personaltax return. Funds earn interest tax-free.Reimbursements for qualified medicalexpenses are excluded from income.Employee may withdraw funds for non-medical expenses subject to

income and excise tax.

Employee Tax SavingsContributions are made Pre-Tax.

Reimbursements for eligible expenses are excluded from income.

The information in this document represents a summary of the information only as of the date referenced below and does not constitute a guarantee of any benefit nor limit CONEXIS’ ability to requireadditional substantiation of a claim. Refer to the published IRS documents for specifics. Health FSAs and HRAs are covered under IRS Section 105 and 106. Health FSAs are subject to additional rules setforth in the regulations under IRS Code Section 125. HRAs are subject to additional rules set forth in Notice 2002-45 and Rev. Rul. 2002-41. HSAs were established under the Medicare Reform Package,covered under IRS Code Section 223.

* As part of the Tax Relief and Health Care Act of 2006, HSAs can now be funded with a one-time tax free rollover from an existing FSA or HRA (a "Qualified HSA Distribution") provided certain conditions are satisfied(this provision is effective upon enactment but expires January 1, 2012).

**Maximum contribution requires either full year eligibility or initial eligibility as of 12/01 and continuation of eligibility throughout the following year.

No – however, an employer may establish annual plan limits.

Maximum StatutoryContribution**

(2010)No – however, an employer may


$5,950 min (single)$11,900 min (family)

$3,050 max (single)$6,150 max (family)

$1,000 max (catch up contribution for individuals age 55 or over)

HRAHealth Reimbursement Arrangement

HSAHealth Savings Account

FSAFlexible Spending Account


wordandbrown.com

What Expenses Typically Qualify* Under An HRA, HSA, or FSA?

HRAs and Health FSAs are subject to Code Section 105 generally; therefore, only expenses that qualify as medical careunder Code Section 213(d) are eligible for reimbursement, subject to some additional restrictions:

• In accordance with Code Section 106, HRAs cannot reimburse expenses for qualified long term care services• In accordance with Code Section 106 and 125, Health FSAs cannot reimburse expenses for qualified long term

care services and/or insurance premiums

HSAs are subject to Code Section 223; therefore, only expenses that qualify as “medical care” under Code Section 213(d)are eligible for tax free reimbursement except as otherwise limited by Code Section 223:

• No insurance premiums except for long term care premiums, COBRA premiums, health coverage received whilereceiving unemployment compensation, and any deductible health insurance coverage for individuals who areage 65 or older, other than Medicare Supplemental Policies.

Medical Expenses:

Fees paid to the following providers for treatment of a specific disease:

• Acupuncture• Ambulance hire• Artificial limbs and teeth• Automobile modifications (hand

controls, special equipment, mechanicallifts if for handicapped persons)

• Braille books & magazines• Contact lenses & solutions• Crutches/slings• Doctor copays• Examination, physical• Eye examination

• Eyeglasses• Hearing devices• Hospital bills for medical care• Iron lungs, operating cost• Laetrile, when prescribed by doctor• Laser eye surgery• Lip reading lessons for the

hearing impaired• Eligible over-the-counter

(OTC) medications*• Nursing care• Obstetrical expenses

• Operation• Oxygen equipment• Prescription drugs for medical care• Rental of medical or healing equipment

(requires doctor’s note)• Seeing-eye dogs• Telephones for the hearing impaired• Transportation expense relative to illness

(including doctor’s office)• X-Rays

• Chiropodist (expense)• Chiropractor• Clinic• Dentist• Doctor• Gynecologist• Hospital• Laboratory• Midwife• Nurse

• Obstetrician• Oculist• Ophthalmologist• Optician• Optometrist• Oral Surgeon• Osteopath• Pediatrician• Physician• Physiotherapist

• Podiatrist• Practical nurse• Psychiatrist• Psychoanalyst• Psychologist• Psychopathologist• Sanitarium• Specialist• Surgeon

Common expenses that are not eligible for reimbursement include: Cosmetic surgery for non-medical reasons (including liposuction, hair transplantsand electrolysis), weight loss programs (unless physician prescribed for treatment of a specific illness including obesity) and orthodontia services notreceived during the plan year.

FSA expenses must be incurred (i.e. services rendered) during the plan year.

Funds can be withdrawn from an HSA Account for other purposes; however, the withdrawal amount will be subject to taxes and penalties. Pleaseconsult your tax advisor.

*The information in this document represents a summary of information only and does not constitute a guarantee of any benefit nor limit CONEXIS’ability to require additional substantiation of a claim. Please refer to the plan summary that your Health Plan will provide for complete details onthe plan’s benefits, limitations and exclusions for your selected plan. For details concerning your rights and responsibilities with respect to your HSA(including information concerning the terms of eligibility, qualifying High Deductible Health Plan, contributions to the HSA, and distributions from theHSA), please refer to your HSA Custodial Agreement. OTC list available on request.

Qualified expenses must be for out-of-pocket medical care for the diagnosis, cure, mitigation, treatment or prevention ofdisease, or for the purpose of affecting any structure or function of the body.

127


Planning

During this phase, there is fact-finding and analysis betweenCONEXIS and the client toidentify past problems, currentissues, and future concerns andto gain an understanding of theobjectives of the implementationprocess.

IMPLEMENTATION PROJECT OVERVIEW

Phase IFACT FINDING

Executing

Phase IISYSTEM DEVELOPING

Monitoring & Controlling

Phase IIIAUDITING

Closing

Phase ITRANSITIONING

Objectives of Phase I of theImplementation Project are:

· Scheduling a kick-off call to introduce the partiesinvolved, their positions and titles, and theirresponsibilities in theimplementation process.

· Gathering information,which is a critical, on-goingpart of the implementationprocess.

· Understanding anddocumenting the businessrules that define and governthe business needs andrequirements of the client.

· Understanding what isneeded for system setup ofthe client.

· Setting a timeframe forweekly status calls toaddress issues that mayarise during the processand to make and documentdecisions about theprocess.

· Creating a project plan thatis updated throughout theprocess detailing tasks,responsibilities, dates, andmilestones.

During the phase, the BusinessRequirements gathered inPhase I are converted toSystem Requirements. Withanalysis complete, designing,constructing, and testing areperformed.

Objectives of Phase II of theImplementation Project are:

· Designing account structure(i.e., plans and rates forCOBRA; maximums andminimums for FSA) toensure consistency between the client, CONEXIS, and the carriers.

· Building account structurein system.

· Scheduling file specificationmeeting(s) between ITcontacts from CONEXISand client.

· Testing both inbound andoutbound eligibility datatransfer.

· Working with third parties asneeded

During this phase, the ProjectPlan is reviewed to ensure thatproject deliverables andmilestones have been met. Bothquantitative and qualitativemeasures are performed.

Objectives of Phase III of theImplementation Project are:

· Auditing by CONEXIS,which consists of threetollgates to ensure accuracyof information concerningbusiness rules, data, andfiles.

· Auditing by client, whichincludes sign-off of issues.

· Web site training.

Throughout the ImplementationProject, the AccountRepresentative is involved,taking part in meetings andcalls, gaining an understandingof the business rules defined bythe client. This ensures thattransition is as seamless aspossible.

Objectives of Phase IV of theImplementation Project are:

· “Going live” with productionsystem allowing webaccess for client andparticipants.

· Transitioning withinCONEXIS fromImplementation to ClientServices.

· Signing-off of project byinvolved parties.

· Reviewing lessons learned.

Note: This is intended as a high-level overview. As the project progresses and questions arise, the CONEXIS Implementation Team isavailable to answer any questions via telephone at (800) 869-6989, X 2400

129


DENTAL

130


Are there anyindustries that are

ineligible?

Are there anyindustries that

receive anautomatic rate

load?

Do you offer OpenEnrollment to DMO

& DPO groups attheir anniversary

each year?

At OpenEnrollment, do

members have anyrestrictions (such asreduced benefits ora waiting period)?If yes, please providebrief explanation of

restriction:

Is there a waitingperiod for majorservices for newhires (includingEnrollees who

initially waived thewaiting period)?

Aetna

Allied National

BEST Life& Health

Insurance

Blue Shield

CaliforniaChoice®

Delta Dental

Delta Dental/Morgan White

Freedom DentalPlans

(BEN-E-LECT)

DENTAL PLAN COMPARISON CHART

Yes Yes DMO:N/A

DPO:Yes

Yes—Groups with 2-4enrolled will have 12

month wait. 5+ waivedwith prior coverage.

10+ waived automatically

Yes—see WaitingPeriod/Takeover

section on page 140

Golden West

No Yes—see specialconsiderations section

on page 138 for acomplete listing

N/A N/A 12 month wait for major services

No No N/A N/A N/A

Yes—if writtenstandalone

No Enrollment is possible for any

employee to elect dentalplan coverage during

the first 31 days of initial eligibility

An employee or dependent whodoes not enroll within 31 days offirst becoming eligible (or after aqualifying life event) is subject tothe Late Entrant Provision. They would have a 12-month waiting

period for Basic & Major services; and 24-month waiting period for Orthodontia

Waiving of the waiting periodis done at the group level.

Employers with prior dentalcoverage, and their new hires,

will not be required to meet a waiting period prior toservices being rendered

Yes—see SmallEmployer Group

Sales Guide (Ineligible Categories)

No DHMO:Yes

PPO:Yes—but there could belate entrant for memberswho were not previously

enrolled

Yes—see SmallEmployer Group

Sales Guide (Late Entrant

Provision)

DHMO:No

PPO:There could be,

based on plan sold

PPO:Yes

DeltaCare USA:No

PPO:No

DeltaCare USA:Yes

Dual Choice:Yes—for switching between

plans, but not for addinglate enrollees/dependents.

PPO: N/A

Voluntary PPO:Yes—new employees are

subject to a 12 month waitingperiod regardless

of previous coverageDeltaCare USA & Dual Choice:

No

PPO:No

DeltaCare USA:No

Voluntary PPO:Yes

No No DMO:Yes

DPO:Yes

Yes—same as new hire

DMO:No

DPO:Yes

Yes—excludedindustries include

dental offices or otherorganizations

associated with the dental profession

No Yes—all plan changes are available at group anniversary

No 12 month wait for major benefits for lateenrollees and add-ons

with no prior dental plan.No waiting period forindividuals with prior

dental

No No DHMO:Yes

DPPO:Yes

No restrictions—it is a true

open enrollment

All Non-Voluntary DHMO & DPPO:

No waiting period for newhires and no waiting period

for those who initially waived(as long as they enroll duringopen enrollment). Note our

Voluntary plans do have a 12month wait for major services

all enrollees

See page 146

131



Are there anyindustries that are

ineligible?

NoNo DHMO:Yes

DPPO:Yes

DHMO and DPPO:No restrictions

DHMO:No

DPPO:Yes

Are there anyindustries that

receive anautomatic rate

load?

Do you offer OpenEnrollment to DMO

& DPO groups attheir anniversary

each year?

At OpenEnrollment, do

members have anyrestrictions (such asreduced benefits ora waiting period)?If yes, please providebrief explanation of

restriction:

Is there a waitingperiod for majorservices for newhires (includingEnrollees who

initially waived thewaiting period)?

Health Net

KaiserPermanente

Choice Solution


Principal LifeInsuranceCompany

MetLife/Safeguard

SelectDent

SmileSaver

Yes—dentaloffices/dental labs

No DMO:Yes

DPO:Yes

No DMO:No

DPO:MetLife offers plans with

and without waitingperiods for major services

Yes Yes DMO:Not available

DPO:Yes—removing the

open enrollment periodis available. Call

your Word & Brownrepresentative

Yes—If a member has beenenrolled in the coverage

before, voluntarilydisenrolled and then enrolls

again (even during theopen enrollment period),he/she is subject to a late

entrant waiting period

DMO:Not available

DPO:No—waiting periods areoptional, however, andavailable upon request

through Request a Quote

HSA California® No No DMO:Yes

DPO:Yes

Yes—same as new hire

DMO:No

DPO:Yes

Yes—dental offices No—however 10% load for groups with

no prior coverage

Yes—must meetparticipation

No No Waiting Period

NoNo DHMO:Yes

PPO:Yes

No No

No No DMO:Yes

DPO:N/A

No DMO:No

DPO:N/A

Reliance Standard

YES—Dentist Offices & Labs, AssociationGroups/MembershipOrgs/Fraternal Orgs,Trusts, and Unions

YES—Jewelry-relatedBusinesses, AutomotiveDealers, Direct Selling

Businesses (House to House,Street Vendors, etc.),

Security/Commodity Dealers,Real Estate Agents/Developers,

Beauty Salons, FuneralServices, Educational Services

and Carve-Out Groups

DMO:N/A

DPO:No

DMO:Not available

DPO:No—waiting periods areoptional, however, andavailable upon request

through Request a Quote

No Open Enrollment. If aninsured is deemed a Late

Entrant, benefits are limitedto exams and cleanings for

adults and exams,cleanings, and fluoride

treatment for children forthe first 12 months

No No DHMO:Yes

DPO:Yes

DHMO:No waiting period

DHMO:No

DPO:Depends on plan

UnitedHealthcare No No DPO:Yes

No DPO:No

132


Aetna

Allied National

BEST Life& Health

Insurance

Blue Shield

CaliforniaChoice®

Delta Dental

Delta Dental/Morgan White

Freedom DentalPlans

(BEN-E-LECT)


DMO:N/A

DPO:Yes—in-network discount applies

Yes

No state restrictions

Yes Yes

Golden West

Do any of your plans cover/include

a discount forimplants?

Do any of your plans

cover/include adiscount for teeth

whitening?

Are employeeswho reside outside

of Californiaeligible?

Any staterestrictions?

Are 1099employees eligible?

Out of NetworkClaim Adjudication

No Yes


UCR 80th Percentile(option to purchase

90th)

No No Yes

States allowed:AL, DE, DC, FL, GA,

LA, MD, MS, MT, NV,NY, PA, TX, UT & WV

Yes Yes

No50% of primaryenrollees may resideoutside of California

See page 146

DMO Access:Provides discounts fornon-covered services

DPO:No

Yes


No Refer to out of networkclaim adjudication

section on page 136

DHMO:Yes—with

cosmetic rider

PPO:No

No DHMO:No

PPO:Yes


Yes Either MAC or UCR on PPO

No DMO:No

DPO:Yes

No DMO:N/A

DPO:UCR

No No Yes

Call your Word & Brownrepresentative to

determine any staterestrictions

Yes—if they work full-time for one

employer

2 Options:PPO Network

Allowance or

80th percentile of UCR

No Yes

No state restrictionson DPPO plans

No OON adjudication forDPPO is MAC or UCR

depending uponplan.

Discount benefit only

DMO:N/A

DPO:Yes—In-network discount applies

PPO:No

DeltaCare USA:Yes

DMO:Yes—external bleaching only

DPO:No

No

No Yes

PPO:No

DeltaCare USA:No

133


Health Net

KaiserPermanente

Choice Solution


Principal LifeInsuranceCompany

MetLife/Safeguard

SelectDent

SmileSaver


Do any of your plans cover/include

a discount forimplants?

Do any of your plans

cover/include adiscount for teeth

whitening?

Are employeeswho reside outside

of Californiaeligible?

Any staterestrictions?

Are 1099employees eligible?

Out of NetworkClaim Adjudication

DMO:No

DPO:Yes—groups of 10+

DMO:Yes—the SGX seriescovers whitening at aspecified copayment

DPO:No

DMO:Employees residing in

CA, TX or FL can accessDMO benefit

DPO:Yes – National Network

DMO:No

DPO:No

DMO:N/A

DPO:80th percentile is standard.MAC, 70th, 90th and 99th

UCR plans available

DMO:Not available

DPO:No—but implant coverage

is available as a majorservice or through aseparate benefit rider

DMO:Not available

DPO:No—but coverage

for teeth whitening isavailable through a

separate benefit rider

Yes

Benefit and ratingrestrictions may apply

No Call your Word & Brown

representative for other percentiles

DHMO:teeth whitening

covered with a copayment

DPPO:Not covered

No DHMO:No—DHMO coverage

is for CA employees only

DPPO:Yes—there are

no state restrictions

Yes 80th percentile of UCR

Yes—on the Voluntary

Deluxe Plus

N/A YesNo state restrictions;

as long as the company is

based in California it willcover all employees

Yes—as long as thecompany can show

that at least twoemployees are on

the payroll

Yes—80th percentile on the Deluxe and

Deluxe Plus

DHMO:External bleaching

only

PPO:No

No DHMO:No

PPO:Yes

No DHMO:No

PPO:UCR

DMO:No

DPO:N/A

DMO:No

DPO:N/A

No Yes N/A

Reliance Standard

DMO:N/A

DPO:No

DMO:N/A

DPO:No

Yes


Yes The out of network claimallowance level depends on ifthe Managed Care Option isquoted. If the Managed CareOption is chosen, then the outof panel allowance is MAC. Ifthe Managed Care Option isnot chosen, then the out of

panel allowance is U & C 80th

No No No Determined byemployer

PPO & Indemnity: Out of network claims

are paid based on the 80th percentile

of MDR

HSA California® No DMO:No

DPO:Yes

No DMO:N/A

DPO:UCR

DMO:Yes—external bleaching only

DPO:No

UnitedHealthcare DPO:No

DPO:No

Yes—either PPO orIndemnity available in

all 50 states

Yes—no more than25% of the enrolled

population

N/A

NOTE: Contributory Plans are available to groups of 2 if sold with Aetna medical; Voluntary is down to 3 with medical

* When using the Freedom of Choice plans, members may switch between the DMO and PPO plans on amonthly basis by calling member services. Plan changes must be made by the 15th of the month to beeffective the following month.


CALIFORNIA COVERAGE AREA


California HMO Counties:

Boxes containing a number indicate that these coordinate plans offered by this carrier can bewritten together to create a dual option package. The number indicates the minimum enroll-ment required on each of the coordinate plans. Blank boxes indicate which plans cannot bewritten together. (No dual option available with voluntary plans.)


Customer Service, Bilingual Support,& Broker Services877-238-6200


ClaimsP.O. Box 14094Lexington, KY 40512

Fax (Add-ons/Deletes)888-258-4528

Provider Services888-632-3862

PRODUCTS OFFERED

California PPO Counties:

California Indemnity Counties:







HMO Network

PPO Network

Indemnity Network

135







Call your Word & Brown representativeDMO Access

DMO Plus

* *

* *

DMODMO AccessDMO Plus

DMO/DPPOFreedom of Choice Basic†

Freedom of Choice Plus

3-503-50

3-503-50

Contributory Plans Group Size

NOTE: Plans may not be available in all zip codes within a county. Checkwith your Word & Brown representative to confirm if coverage is avail-able for your group location.


DPPOPPO $1000 ActivePPO $1500 PPO $1500 ActivePPO $2000

3-503-503-503-50

DMOVol. DMO AccessVol. DMO PlusVol. PPO $1000 ActiveVol. PPO $1500Vol. PPO $1500 Active

3-503-503-503-503-50

Voluntary Plans Group Size

Coverage waiting period on voluntary plans: must be enrolled on plan for 12 months before becoming eligible for major services

PPO $1,000PPO $1500PPO $2000Vol. PPO $1,000

3-503-503-503-50

Out of State Plans Group Size

Waiting periods will be waived at thegroup level if prior carrier creditablecoverage is provided

PPO 1000Active

PPO 1500

PPO 1500Active

PPO 2000

*

*

*

*


Call your Word & Brown representativeCall your Word & Brown representative



DE

NT

AL

Employees

Dependents

Employees

Dependents



Any ineligible industries?

Virgin groups eligible?

DE-6 statements required?

Employees

For Dependents

% of Total Cost:

RATING INFORMATION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*


ORTHODONTIC COVERAGE

WAITING PERIOD WAIVER/TAKEOVER


OUT OF NETWORK CLAIM ADJUDICATION


Group Size

Rate Guarantee



136


MINIMUMEMPLOYERCONTRIBUTION

3-50 Standalone (2 with Aetna medical)


12 Months

No

100% and 50% of all employees

N/A

◆◆ 75% and 50% of all employees

N/A

50%

OR

25%

No

No

No

N/A



Yes—if written standalone


No—Employer Dental Certification Form needed ifstandalone

Included for groups 10 plus. 12 month wait thencovered 50% in-network only, except for PPO Activewith a 40% out-of-network benefit. Ortho waitingperiod is waived for employees covered by thegroup’s immediately preceding dental plan. Towaive ortho wait, the group’s immediately precedingplan must have covered ortho services

PPO $1500 - Lifetime maximum $1,000PPO $2000 - Lifetime maximum $1,500

Included for groups 10 plus. DMO Plus - $2,300 copayDMO Access - $2,300 copay

Takeover coverage, where prior carrier covered major dentalservices, but excluded orthodontia: Waiting period will notapply to covered major dental services, but will apply toorthodontia (if the new Aetna plan covers orthodontia) forexisting members and new hires.

Takeover coverage, where prior carrier covered both majordental services and orthodontia: Waiting period will not applyto either major dental services or orthodontia for existingmembers and new hires.

Voluntary has an enforced 12 month waiting period on majorservices.

Freedom of Choice plans: members get to choosebetween the DMO and PPO plans on a monthly basis bycalling member services. Plan changes must be made bythe 15th of the month to be effective the following month.

DMO

PPO

Included DMO only - $2,300 copayFreedom of Choice


Freedom of Choice Basic Scheduled Fee

PPO $1000 Active, PPO $1500, PPO $1500 Active, Freedom of Choice Plus,Vol. PPO $1000 Active, Vol. PPO $1500, Vol. PPO $1500 Active UCR 80%

PPO $2000 UCR 90%






PRODUCTS OFFERED







Are rates for Out-of-State employees based on the CAEmployer Zip code or based on Out-of-State Zip Code(and separate rates)?


137


N/A

N/A

All Counties

N/A Standard Base Indemnity** 2-99

N/A

N/A

* Employers may customize base plan benefits shown above by electing these plan options shown above (with rate factors as shown):$1500 annual maximum 1.10$2000 annual maximum 1.17$10 preventive and diagnostic copay .980 month basic services waiting period 1.22$50 deduct. (basic & major services combined) 1.06$100 lifetime deduct. (basic & major services combined) 1.02Endodontics/periodontics to Basic Svcs (10+ EEs only) 1.13Orthodontia $1500 max. benefit ($500/yr) 1.09†

90% U&C 1.04Child Sealants 1.11

No dual option available

NOTE: Plans may not be available in all zip codes within a county. Checkwith your Word & Brown representative to confirm if coverage is avail-able for your group location.

Yes

Insureds can choose any dentist forservices without penalty. However avoluntary discount network using theAIG Dental Network SM is available.Voluntary use of a dentist in thisnetwork may help reduce co-insurance costs.

HMO Network

PPO Network

Indemnity Network

Prepaid/HMO Group Size

PPO Group Size

Indemnity Group Size

†Apply to ortho rates only

**Currently not quoting on our system

N/A

All states are allowed for Out-of-State employees as long asemployer is in an approved state. Allied National is notapproved in WA and NC

Indemnity plans only - with a nationwide passive PPO network

For any "multilocation" group, contact your Word & Brownrepresentative for proper rating. We will rate based on thelocations of the multiple employers offices or Out-of-Stateemployees (i.e. salespeople who work out of their home)

N/A

N/A

DE

NT

AL

Member Support, Customer Service, & Commissions:Allied National 800-825-7531

BillingPremium DepartmentAllied NationalP. O. Box 29188Shawnee Mission, KS 66201-9188Ph. 800-825-7531 • Fax 913-945-4390

ClaimsUnited States Life Insurance Company P.O. Box 1581 Neptune, NJ 07754-1581 800-221-3480


General Fax #:913-945-4390


If the group has had a comparable Indemnity/PPODental plan in force, employer may elect Takeover. If Takeover criteria is met and the employer elects it,employees and dependents currently covered by theemployer’s plan will get deductible and waitingperiod credit. Rate factor based on group size andplan design applies to groups with takeover.

Option--0 month Basic Services waiting period maybe elected by employer. Apply 1.22 factor to rates.

Indemnity Base PlansDependent children (under age 19) only. One time$50 deductible then 50% to $1000 lifetime max. perperson while insured. 12 month waiting period.

Option--$1500 lifetime max. per person ($500/year).Apply 1.09 factor to ortho rates only.

Employees

Dependents

Employees

Dependents






Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*





Group Size

Rate Guarantee



138

Yes

Yes

Yes

Same minimum group size for non-carve out group(see Products Offered section on previous page)

2-4

2-99

25%

N/A

N/A

2-99

1 Year

Yes

5-99

◆◆ 75%

◆◆ 50%

100%

100%

100%

50%

Pre-authorization required for all services over $300.

100% family-related groups are now eligible for coverage with a 20%rate load.

Plan administered by Allied National and underwritten by The UnitedStates Life Insurance Company of New York, a member company ofAmerican International Group, Inc.

The following Industries receive an automatic rate load:3843 Dental Equipment and Supplies5813 Drinking Places (Alcoholic Beverages)7929 Bands, Orchestras, Actors, and Other Entertainers and

Entertainment Groups8021 Offices and Clinics of Dentists8111 Legal Services8211 Elementary and Secondary Schools8299 Schools and Educational Services, NEC6531 Real Estate Agents and Managers7941 Professional Sports Clubs and Promoters8661 Religious Organizations8023 Orthodontists






No

Yes—as long as they work full-time and exclusivelyfor one employer. Must be approved by Allied priorto case submission.

No

Yes

Groups of 2-9: Yes 10+ groups: No

Two Usual & Customary options available:80th percentile of HIAA (base)90th percentile of HIAA (1.04 rate factor)

◆◆ 100%

◆◆ 100%** One employee may waive that doesn’t fit ◆◆ category.








Boxes containing a number indicate that these coordinate plans offered by this carrier can bewritten together to create a dual option package. The number indicates the minimumenrollment required on each of the coordinate plans. Blank boxes indicate which plans cannotbe written together


PRODUCTS OFFERED









139


PPO Network

N/A

See First Dental Health website for county info at www.firstdentalhealth.com

All Counties

BEST PPO OptionDental(Offered only through Word & Brown)

2+ PPO HighPPO MidPPO Basic1

PPO Voluntary HighPPO Voluntary MidPPO Voluntary Basic1

2-1492-1492-1492-1492-1492-149

Indemnity HighIndemnity MidIndemnity Basic1

Voluntary Indemnity HighVoluntary Indemnity MidVoluntary Indemnity Basic1

2-1492-1492-1492-1492-1492-149

First Dental Health (CA only)www.firstdentalhealth.com

Diversified Dental Services(Nevada)www.ddsppo.com

Dentemax (National)www.dentemax.com

Basic

NOTE: Plans may not be available in all zip codes within a county. Check with your Word & Brown representative to confirm if coverage isavailable for your group location.

Group Size PPO Group Size Indemnity Group Size

Note: Custom Quotes available for groups of 150+. Call your Word & Brown representative.1 Currently not quoted on the Word & Brown system. Call your Word & Brown representative for more

information

BasicSTD/

STD OrthoStar/

Star PlusElite/

Elite Plus

STD/STD Ortho 2

2

Elite/Elite Plus 2

2

2

2

2

2

2

2

2

2

BEST Basic Voluntary1

BEST Standard VoluntaryBEST Basic1

BEST StandardBEST Standard OrthoBEST StarBEST EliteBEST Star PlusBEST Elite Plus

5-995-993-993-993-993-993-993-993-99

Minimum of 2 employees must enroll on each plan. Voluntary plan not available for dual option.

BEST PPO OptionDental

Star/Star Plus

PPO High/Mid/Basic

PPO (All) Indemnity (All)

Indem High/Mid/Basic 5

5

Minimum 10 employees must enroll in order for group to be eligible for Dual Option. A minimumof 5 must enroll on either plan.

BEST PPO & Indemnity

5

5

2

2

2

Yes

There is no minimum, since BEST Health Plans can blendthe rates for a multi-state group. They do prefer at least50% of the group in the state where the business resides.

All states allowed

BEST Health Plans can offer a dual option for groups over 10which would work well for a group with many employees outof state. The group could offer a PPO Plan in California andan Indemnity Plan for all Out-of-State employees

If the group had at least 50% of the employees in CA the groupwould most likely be based on the CA Employer Zip Code

N/A

DE

NT

AL

Member Support, Customer Service & Commissions:[email protected]

BillingBEST Life and Health Insurance Co. 2505 McCabe WayIrvine, CA 92614-6243

ClaimsBEST Life and Health Insurance Co. P.O. Box 890Meridian, ID 83890800-433-0088Fax 208-893-5040Email: [email protected]


Yes—if group has a carve out in place with prior dental carrier.

Yes—if group has carve out in place with prior dental carrier.

No

Minimum of 10 employees enrolled as long as priorcoverage exists with all 10 on dental carrier billing.


Employer-sponsored PPO/Indemnity

Employees

Dependents

Employees

Dependents






Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Associations?

Minimum group size

CARVE OUTS*






Group Size


140

EmployerSponsored 2+

50%

N/A

N/A

No

CA-NoNV-Yes

Yes

Yes

Yes—for groups enrolling less than 5 employees

*Contributory: 2+ / Voluntary: 5+

N/A

N/A

N/A

◆ 60%

N/A

◆ 60%

N/A

5+

N/A

20%

N/A

Two options available:1 80th percentile of UCR (based on Ingenix data)

Word & Brown quote reflects this option

2 90th percentile of UCR (based on Ingenix data) - Apply a1.02 load to rates shown on Word & Brown quote

Employer Sponsored & Voluntary: 12-month wait on all classIII and class IV services, waived for groups of 5 to 9 withcomparable coverage. For groups with 10+ employee livesenrolling, waiver is given to groups without prior comparablegroup coverage. Late entrant provision does not apply during open enrollment.

5+ Optional Adult ortho available for groups with 25+employees enrolling on PPO or Indemnity. Adult ortho$1,000 max. Optional child ortho available for enrolleddependent children through age 20 on groups with 2+employees enrolled on PPO or Indemnity. $1,000 and $1,500Lifetime Max. available




25+

Supplemental Dental Accident Benefit included in High, MidPPO, Indemnity and IndemnityPlus Basic plans—up to $1,000per accident; and Basic—up to $500 per accident. Children’s Good Vision Benefit—Exam included in all PPO andIndemnity plans. 50% of eligible expenses, once every 12months, for children with ortho coverage. QualSight-LASIKdiscount access plan available. 5% discount on dental bypurchasing vision.

Voluntary Plans5+

Yes

Min. 5 enrolled

100%

N/A

2-4

Voluntary PPO and Indemnity:High or Mid Plans - Optional Child ortho available for groupswith 5+ employees enrolling on PPO or Indemnity. $1,000and $1,500 Lifetime Max. available

Basic Plans - Optional Child ortho available for enrolleddependent children through age 20 of groups with 5+employees enrolling on PPO or Indemnity. $1,000 and$1,500 Lifetime Max. available

*$20 per month admin. fee for groups of 2-5

N/A

N/A

Rate Guarantee


1 year; 2 year guarantee available for:Employer contributory: available forgroups with 10+ enrolling and there willbe a 7% loadVoluntary: available for groups with 10-50enrolling and there will be an 8% load



DUAL OPTION (MIX AND MATCH) PROVIDER INFORMATION

PRODUCTS OFFERED







141


DHMO Basic DHMO Plus DHMO Deluxe DHMO Voluntary

2-50 2-50 2-50 2-50

Smile Basic Voluntary 75/1000/No Ortho/MACSmile Basic 75/1000/No Ortho/MACSmile Value 50/1500/No Ortho/MACSmile 50/1500/No Ortho/MACSmile Plus 50/1500/Ortho/MACSmile Plus Gold 50/1500/Ortho/U85Smile Deluxe 2000 50/2000/No Ortho/MACSmile Deluxe 50/1500/Ortho/MACSmile Deluxe Plus 2000 50/2000/Ortho/MACSmile Deluxe Gold 50/1500/Ortho/U85

2-502-502-502-502-502-502-502-502-502-50

Smile Basic 75/1000/No Ortho/MACSmile Value 50/1500/No Ortho/MACSmile Deluxe Plus 2000 50/2000/Ortho/MACDHMO BasicDHMO Plus

Blue Shield of California Dental HMO

Blue Shield of California Dental PPO

All Counties

California DHMO Counties:

California DPPO Counties:

Alameda, Butte, Contra Costa, El Dorado, Fresno, Kern, Los Angeles, Marin, Monterey, Napa, Orange, Placer, Riverside, Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma, Stanislaus, Sutter, Ventura and Yolo

N/ACalifornia Indemnity Counties:

NOTE: Plans may not be available in all zip codes within a county. Check with your Word & Brown representative to confirm if coverage is available for your group location.

*See Special Considerations on the following page concerning enrollment requirements when Dental PPO is sold with Blue Shield Medical.


DPPO Group Size

Suite Deal Dental

Group Size

Blue Shield members with Dental PPO benefits can access a newnationwide provider through DentalBenefits Providers Inc.

Dual Option available to groups of 2 or more eligible employees in any of these combinations:● 2 DPPOs● 2 DHMOs● 1 DPPO + 1 DHMO● 1 DPPO Voluntary + 1 DHMO Voluntary● 1 Voluntary + 1 Non-Voluntary

Non-Voluntary or Non-Voluntary + Voluntary Dual Option: Minimum 50% employer contribution and minimum 75% participation.

Voluntary Dual Option: No employer contribution or participation requirements

Suite Deal Dental:There is a minimum participation requirement of 65% of eligible employees. All plans must beoffered, however enrollment in all 5 plans is not required. Suite Deal Dental package can be soldalongside any Blue Shield of California or Blue Shield of California Life and Health Insurance Companyproducts, or on a stand alone basis.

DHMO Network

DPPO Network

Yes

51% of the full time employees must reside in California

The following states have no dental provider access soDPPO benefits will be paid as out of network: North Dakota, South Dakota, Vermont, Alaska, Montana &Wyoming

All of Blue Shield’s DPPO plans are available

Rates are based on the California Employer zip code

N/A

Member Support, Customer Service,& Commissions:Dental Claim Forms: 888-702-4171

DPPO Member Support and Customer Services: 888-702-4171

DHMO Member Support and Customer Services: 800-585-8111

Commissions: Blue Shield Producer Services 800-559-5905

Dental Benefits Provider 800-445-9090

ClaimsBlue Shield P.O. Box 272590Chico, CA 95927-2590

Add-ons/Deletes) Fax 209-367-6475

2-502-502-502-502-50

DE

NT

AL

2-50(Single or

Dual Option)

Employees

Dependents

GROUP SIZE


Smile Basic Voluntary, Smile Basic, Smile Value, Smile & Smile Deluxe 2000: Not CoveredSmile Plus, Smile Plus Gold, Smile Deluxe, Smile Deluxe Plus 2000 & Smile Deluxe Gold: 50% - max. $1000 per calen-dar year. (The annual maximum for orthodontics is in additionto the annual maximum for other covered services.)

DPPO

DHMO Basic: Adult-$2650 Copay/Child-$2350 Copay DHMO Plus: Adult-$1700 Copay/Child $1400 Copay DHMO Deluxe: Adult-$1500 Copay/Child-$1200 Copay DHMO Voluntary: Adult-$2650 Copay/Child-$1800 Copay

DHMO






No

No

No

Yes

No—if standalone dental; Yes—if sold with medical (reconciled). Submit payroll register for employees not listed on DE-6

Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*







Group Size

Rate Guarantee



142

Yes—75% of carve-out must enroll



If dental only, minimum 8 enrolled employees;If medical and dental, minimum 8 enrolled employees

50%

N/A

N/A

2-50

12 Months

No

2-50Voluntary

N/A

N/A

N/A

DHMO N/ADPPO Smile Basic, Smile Basic Voluntary, Smile Value,

Smile, Smile Plus, Smile Deluxe, Smile Deluxe 2000,and Smile Deluxe Plus 2000 pays OON dentistsbased on the Blue Shield negotiated fee (MaximumAllowable Charge or MAC) schedule. Smile DeluxeGold and Smile Plus Gold U85 pays OON dentistsbased on HIAA 85th percentile.

DHMO No waiting period DPPO No waiting period except for

DPPO voluntary planIndemnity N/A

N/AIndemnity




A group may add dental off anniversary as long as it isnot within 60 days of the anniversary date of Blue Shieldmedical plan coverage. If within 60 days of renewal, BlueShield asks group to wait until medical renewal and thenadd dental. This does exclude new plans (until the newplans have been on the market for 1 year). The new plansmay only be added at anniversary. Groups can change toa different plan only at the anniversary date of Blue Shieldmedical plan coverage or the effective date of a newdental contract.

If a group cancels coverage, the group must wait 12months to re-apply for coverage.

2-50Suite Deal Dental

2-50(Single or

Dual Option)

◆◆ 75%

N/A

2-50Voluntary

Min. 2

N/A

2-50Suite Deal Dental

65% total eligibleemployees

N/A

Employees

Dependents

100%

N/A

N/A

N/A

50%

N/A

N/A

100%

N/A



PRODUCTS OFFERED







143


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 3500, and PPO 4000 & 5000WITHOUT Ortho

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

■ Voluntary 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.

HMO Network

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

Plan 3500: All Counties

Plan 4000 & 5000: All Counties

Plan 3500 2-50 Plan 4000Plan 5000

2-502-50

Yes


California EPO 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.

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

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

PO Box 82520Lincoln NE 68501877-203-0036Fax 402-467-7336

SmileSaver SmileSaver Attn: Claims Dept. PO Box 30920 Laguna Hills, CA 92654 800-880-1800

Add-ons/DeletesCaliforniaChoice® Fax 800-558-8000

FDH Access 100+ Plan 3000* Plan 1000

2-502-502-50


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


Indemnity Network


EPO Network

PPO Network

Plan 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

N/A

DE

NT

AL


HMO N/A

EPO & PPO For groups with 10 or more employees,the 12 month waiting period for majorservices will be waived for individualswho were enrolled under this employer’scomparable group dental plan for 12months or more. All new hires andgroups without prior comparable dentalcoverage are subject to the waitingperiod. Credit will be given for time onthe prior plan. If orthodontia was coveredon comparable prior plan, credit will begiven toward the 24 month ortho waitingperiod.


FDH Access 100—$3604 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 waitingperiod 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

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*

HMO




Group Size

Rate Guarantee



144



Union/Non-union?

Minimum group size

Are Commission-Only employees allowed?Yes, if on DE-6 and showing at least minimumwages and withholdings

Are 1099 employees allowed?No

Any ineligible industries?No

Virgin groups eligible?Yes

DE-6 statement 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 3500 - Out of network claims are paid based uponthe 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.

DeltaCare USA Plan 10A DeltaCare USA 10A Vol.DeltaCare USA Plan 11A DeltaCare USA 11A Vol. DeltaCare USA Plan 12ADeltaCare USA 12A Vol.DeltaCare USA 15BDeltaCare USA 15B Vol.

5-99 5-99 5-99 5-99 5-99 5-995-995-99

Classic PPO Voluntary Plan 1000Classic PPO A Plan 1000 Classic PPO A Plan 1500 Classic PPO A Plan 2000Classic PPO B Plan 1000 Classic PPO B Plan 1500 Classic PPO B Plan 2000 Classic PPO C Plan 1000 Classic PPO C Plan 1500 Classic PPO C Plan 2000Options PPO 1 Plan 1000 Options PPO 1 Plan 1500 Options PPO 1 Plan 2000Options PPO 2 Plan 1000Options PPO 2 Plan 1500Options PPO 2 Plan 2000Options PPO 3 Plan 1000Options PPO 3 Plan 1500Options PPO 3 Plan 2000

5-995-495-495-495-495-495-495-495-495-4950-99 50-9950-9950-9950-9950-9950-9950-9950-99

Prepaid plan Group Size PPO Group Size




California Prepaid Counties:


PRODUCTS OFFERED








Prepaid Network

PPO Network

145


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

All Counties

All Counties

PPO: Yes—company must be headquartered in CAPrepaid: No

DeltaCare USA

Delta Dental PPO

Classic Voluntary PPOClassic PPO AClassic PPO BClassic PPO COptions PPO 1 (all)Options PPO 2 (all)Options PPO 3 (all)

5

*

*

*

†

†

†

*

*

*

†

†

†

DeltaCareUSA 10A

Non-Volun.

DeltaCareUSA

10A Volun.Dependent

DeltaCareUSA

10A AllVoluntary

DeltaCareUSA 11A

Non-Volun.

DeltaCareUSA

11A Volun.Dependent

DeltaCareUSA

11A AllVoluntary

DeltaCareUSA 12A

Non-Volun.

DeltaCareUSA

12A Volun.Dependent

DeltaCareUSA

12A AllVoluntary

DeltaCareUSA 15B

Non-Volun.

DeltaCareUSA

15B Volun.Dependent

DeltaCareUSA

15B AllVoluntary

Employer can offer PPO with prepaid plan.* For Classic plans, dual choice requires a minimum enrollment of 10 eligible employees (at least 3 enrolled in one

plan and the balance in the other).† For Options plans, dual choice requires minimum enrollment of 50 eligible employees (at least 10 enrolled in one

plan and the balance in the other).

Customer Service, & Bilingual SupportHMO - DeltaCare USA 800-422-4234

PPO & Dual OptionAllied Administrators 415-989-7443

Member Eligibility 800-765-6003

Commissions & Broker Services 877-472-2669

Claims Delta Dental of California P.O. Box 997330 Sacramento, CA 95899-7330 800-765-6003

Add-ons/Deletes Fax 415-439-5861

PPO: 50%

All states allowed

Rates are based on CA employer zip code

PPO is offered out of state

No

DE

NT

AL

www.deltadentalins.com

5

*

*

*

†

†

†

*

*

*

†

†

†

5

*

*

*

†

†

†

*

*

*

†

†

†

5

*

*

*

†

†

†

*

*

*

†

†

†


Prepaid Plan No out of network coverage

PPO A and PPO Vol Based on Delta Dental PPO fee allowance

PPO B, PPO C, PPO 1, For non-PPO Delta Dental dentists, out of networkPPO 2 and PPO C coverage is their negotiated fee. For non-Delta

Dental dentists, out-of-network coverage is thelesser of the submitted fee or the fee that satisfiesthe majority of Delta Dental dentists for that servicein the same geographical area.


Employees

Dependents

Employees

For Dependents

% of Total Cost:

RATING INFORMATION


Contributory

GROUP SIZE




Group Size

Rate Guarantee



146








Prepaid plan 5-99

3 Options

See Special

Considerations

May be eligible if not paid via 1099 – Call your Word & Brown representative

No

Non voluntary: Yes Voluntary: No

Yes

Prepaid plan: No; PPO: Yes

5-99

1 Year

Prepaid plan: NoNon-Voluntary PPO: YesVoluntary PPO: No

Classic non-voluntary

PPO or Dual Option 5-49

Included: Adult: $1900 Copay; Child: $1700 Copay

Adult: Available for groups of 50-99, 50%—$1000 or $1500 separate lifetime maximum per patient

Child: Available if 10 or more employees enroll. 50%—$1000 separate lifetime maximum per patient. For groups of 50-99, $1000 or $1500 separate lifetime maximum per patient

Available if at least 10 employees enroll on PPO and at least 5employees enroll on prepaid dental plan

Prepaid plan No Waiting Period

Non-Voluntary PPO No Waiting Period

Voluntary PPO One year waiting period for some benefits.Waiting period can be waived with prior fee for service or comprehensive prepaid HMO coverage with no break in coverage

Prepaid plan

Non-Voluntary PPO

Dual Option

Prepaid plan 5-99

Non-Voluntary PPO, Premier or

Dual Option 5-49

◆◆ 100%

◆◆ 100%

◆◆ 100%

◆◆ 100%

GROUP SIZEOptions PPO

or Dual Option

50-99

75%

0%

N/A

Employees

For Dependents

% of Total Cost:


Contributory

Non-Contributory

GROUP SIZEPARTICIPATION

◆◆ 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. If an employee or dependent declines to enroll when they become eligible, they cannot enroll at a later date unless they show proof of loss of coverage

75%

0%

N/A

Classic Voluntary PPO 5-99

0%

0%

N/A

N/A

N/A

Child: Available if 25 or more employees enroll. 50%—$1000 separate lifetime maximum per patient.

Voluntary PPOVoluntary PPO

5-99

3 Options

See Special

Considerations

◆◆ 80%

N/A

Employees

Dependents

Minimum of 5enrollees

N/A

EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Yes, if full time, permanent employeesManagement/Non-management?See footnote below*Union/Non-union?See footnote below*Minimum group sizeSame minimum group size as for non-carve out group. (see ProductsOffered section on previous page)

CARVE OUTS*

* Carve-out (i.e. all types such as management, union, etc.) is available and will requireemployer offer benefits to all classes of employees. Delta Dental PPO will be offered toone population such as management employees and DeltaCare USA will be offered tothe remaining employees. Employer must provide DE-6 identifying the carve-out. Thecarved-out group will receive level 2 rates.

SPECIAL CONSIDERATIONS Transferring a group from an existing Delta Dental or prepaid HMO to small group program is not allowed. Businesses enrolling with the prepaid dental HMO plan maycustomize their employer contribution and enrollment guidelines choosing from these three options:

A) Non-Voluntary enrollmentMinimum employer contribution is 75% of employee and dependent cost. Ifcontribution is 100%, then all eligible employees and dependents must enroll. Ifcontribution is less than 100%, then at least 80% of eligible employees must enroll.Minimum of 5 employees must be enrolled.

B*) Voluntary Dependent enrollment Minimum employer contribution is 75% of employee cost. Employer must providepayroll deduction for dependent coverage. Minimum of 5 employees must enroll butthere is no dependent participation requirement. 80% of eligible employees must enroll. (*Option B rates are shown in our quote.)

C) All-Voluntary enrollmentNo minimum employer contribution but employer must provide payroll deductions foremployees and dependents electing to enroll. Minimum of 5 employees must enroll.

The pregnancy enhancement for Delta Dental PPO groups now includes coverage for thefollowing additional benefits during the year(s) in which a patient is pregnant:1. One additional oral exam; and 2. One of the following:

● An additional prophylaxis (D1110)● Periodontal scaling/root planning, per 4 quadrant (D4341/D4342)

A waiver form is mandatory for all employees declining Delta Dental coverage.

Deductible Rollover Credit is no longer available.

The following industries are ineligible: DeltaCare USA: Law firms and associations; seasonal employment; high turnover 2

Delta Dental PPO: Associations and Trusts1 (except #8661); beauty & barber shops; dentistoffices, dental labs and medical labs; employment agencies; high turnover 2; internationalaffairs; misc. business services; misc. services not elsewhere classified; partnerships;private households; religious organizations (except churches #8661); seasonal employees(Christmas/part-time help); seasonal employees (agriculture);Voluntary PPO: All industries eligible

1 Management and the administrative staff of Associations and Trusts are eligible under Level 1.Use SIC Code 8741

2A business has “high turnover” if 20% or more of the average number of its employees duringthe past 12 months were newly hired for reasons other than the growth of the business.






Customer Service, Bilingual Support,& Broker Services800-800-1397


ClaimsDelta Dental InsuranceCompanyP.O. Box 1809Alpharetta, GA 30023-1809


PRODUCTS OFFERED









PPO Network

Indemnity Network

147


HMO Network

N/A

All counties

All counties

N/A

Delta Dental PPO

Yes—PPO & Premier can be written together

Delta Dental Premier

Yes

N/A

States allowed: AL, DE, DC, FL, GA, LA, MD, MS, MT, NV,NY, PA, TX, UT, WV

PPO and Premier (Indemnity)

Rates are based on out-of-state zip code

All enrollments must be received by the 20th of the month fora 1st of the following month effective date

DE

NT

AL

Platinum PlanGold Plan

1+1+

Delta Dental Premier® Group Size

Platinum PlanGold Plan

1+1+

Delta Dental PPO Group Size

Employees

Dependents

Employees

Dependents






Employees

For Dependents

% of Total Cost:

RATING INFORMATION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*


HMO






Group Size

Rate Guarantee


PPO

Indemnity

Dual Option


148



N/A

N/A

N/A

N/A

1

1+


No

N/AYes

Yes

No

Yes

No

PPO Delta Dental-approved PPO feesPremier®

(Indemnity) Plan allowance based on fees that satisfy the majority of Delta DentalDentists or the submitted fees,whichever is less

N/A

N/A

Platinum Plan: Child only - 0-40-50. $1,000 lifetimemax., $350 per calendar year. Separate $100 lifetimedeductibleGold Plan: N/A

Same as PPO

N/A




















149


N/A

All Counties

Customer Service, Bilingual Support & Broker Services 888-886-7973


Claims Phone 888-886-7973 Fax 559-733-1314 Email [email protected]


Network ChangesPlease email request in writing to:[email protected]

Yes—available for out of state employees for AZ, CA,CO, ID, TX, and UT-based employers

No minimum

All are allowed

All

One rate based on employer location

None

N/A DE

NT

AL

PRODUCTS OFFERED


Employer may offer one plan from the ten plan offerings or may offer all tenplan options from which the employees may select.


PRODUCTS OFFERED

Dental HMO Network

Dental PPO Network

Indemnity Network

N/A

First Dental HealthInterplan Health GroupDentemaxSafeguard DentalConnection Dental by PPO USA

UCR Plans Available

Calendar Year Max

Lifetime Deductible

Preventative

Basic

Endo/Perio

Major

Ortho

$750

$0

80%

80%

50%

50%

FreedomOne

$1,000

$0

100%

50%

50%

50%

FreedomTwo

$1,250

$0

100%

90%

50%

50%

FreedomThree

$1,500

$100

100%

80%

50% (2-9 lives)80% (10+ lives)

50%

FreedomFour

$2,000

$100

100%

80%

50%

FreedomFive

$2,500

$100

100%

80%

50%

50%

FreedomSix

None

$100

100%

80%

0%

FreedomSeven

$1,000

$0

1st $100

Next $500

Next $1,000

FreedomEight

$1,500

$0

1st $100

Next $1,000

Next $1,200

FreedomNine

$1,500

$0

1st $200

Next $1,000

Next $1,000

FreedomTen

50%$350 Annual$1000 Lifetime

100%

80%

50%

Office Visit Copay $20 $20 $20 $0 $0 $0 $0 $0 $0 $0

50%$350 Annual$1,000 Lifetime

For minordependents to age 19 and fulltime students to age 23





Minimum Group Size: 2 enrolled Six PPO Networks Two Out of Network Options Available

50% (2-9 lives)80% (10+ lives)

50% (2-9 lives)80% (10+ lives)

150


Employees

Dependents

Employees

Dependents

Employees

For Dependents

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE



EXCLUSIONS ALLOWED BY CARRIER:Hourly/Salary?Yes

Management/Non-management?Yes

Union/Non-union?Yes

Minimum group sizeMust meet 75% participation rule

CARVE OUTS*




Group Size

Rate Guarantee



Are Commission-Only employees allowed?No

Are 1099 employees allowed?Yes—as long as they work full time, for one employer

Any ineligible industries?Yes—excluded industries include dental offices orother organizations associated with the dentalprofession

Virgin groups eligible?Yes—subject to a twelve month wait for major benefits

DE-6 statements required?Yes

Employer Paid

Group

0-50% of the lowest priced plan

N/A

2-99

12 Months

Yes

Voluntary

Minimum 2

N/A

N/A

N/A

Minimum 2

N/A

2 Options:PPO Network Allowance or80th percentile of UCR

75%—Minimum 2

N/A

Voluntary

0 – 100%

N/A




Available on plans 4, 5 and 10 for dependent childrento age 19 (to age 23 for full time student).

Employer Paid: No waiting period for groups and add-ons with prior dental plans. Late enrollees andvirgin groups have a 12 month wait for major benefits

Voluntary: No waiting period for members withcomparable coverage. 12 month wait for majorbenefits for members with no prior coverage

Groups can elect to have additional waiting periodswaived for an additional fee of 10%

This is a fully insured product. No administration feeapplies.

Employer Sponsored: Employer may make one planavailable or all ten plans available as an option.

Voluntary: Minimum of 2 enrolled, no otherparticipation guidelines.

A $25 monthly billing fee will be added to theemployer’s invoice



DUAL OPTION (MIX AND MATCH)Boxes containing a number indicate that these coordinate plans offered by this carrier can bewritten together to create a dual option package. The number indicates the minimum enroll-ment required on each of the coordinate plans. Blank boxes indicate which plans cannot bewritten together


PRODUCTS OFFERED







151


Customer Service, Member Service,Commissions 800-995-4124

BOR Changes Fax 805-987-2205

Provider Relations 800-995-4124, option 4

ClaimsGolden West Dental P.O. Box 5347 Oxnard, CA 93031-5347

BillingGolden West Dental P O Box 5066Oxnard, CA 93031-5066


2-1242-1242-124 2-1242-1242-124

10-124

10-124

5-124

Golden West

Golden West/WellPointTrue Advantage (Standard)

True Advantage (Select)

Pref.Choice

2†

2†

PrepaidL2

PrepaidL3

† Must have a minimum of 10 eligible employees & 75% participation for dual option. A minimum of 2 employees must enroll on each plan.

* Must have 25% of the eligible employees not covered elsewhere or a minimum of 5members enrolled in the voluntary PPO plan and 2 members enrolled in the voluntaryprepaid plan.

2†

2†

2†

2†

True Advantage (Standard)*

True Advantage (Select)*

Voluntary True Advantage (Standard)*

Prepaid L2 Prepaid L3 Preferred Choice Voluntary Prepaid L2Voluntary Prepaid L3 Vol. Preferred Choice

Vol.L3

Vol.L2

All Counties

All Counties

N/A




NOTE: Plans may not be available in all zip codes within a county. Check withyour Word & Brown representative to confirm if coverage is available for yourgroup location.

Vol. Pref.Choice


PPO Group Size


Vol. True Advantage *

HMO Network

PPO Network

N/A

* * * * *

Groups of 125+ may be submitted to Golden West underwriting for a custom quote. Call your Word & Brown representative * Waiver of major services wait is available to groups with at least 12 months of comparable coverage with a prior carrier.

There is a 5% load to rates to waive the waiting period.

Yes

90%

N/A

PPO dental

CA zip codes

N/A

DE

NT

AL

Standalone DHMO or PPO:Employer must contribute a minimum of 50% of employee’smonthly premium

Dual Choice:Employer must contribute a minimum of 75% of employee’smonthly DHMO premium and thesame dollar amount toward the PPO

Non-Voluntary


Employees

Dependents

Employees

Dependents






RATING INFORMATION

PARTICIPATION

Contributory (EE contributes to premium)

Non-Contributory (ER pays 100% of premium)


GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*

DMO





Group Size

Rate Guarantee


Indemnity

Dual Option


152

Requires prior approval from Golden West



N/A

DHMOOnly2-124

Yes

No

Yes

Yes—needs authorization by carrier prior to submission

No

See Products Offered section on previous page

1 Year

No

HMO N/APPO Standard Fee plans: Out of network claims will be paid

based on the MAC schedule. Member is responsible forcoinsurance plus any charges over the fee scheduleSelect plans: Out of network reimbursement is set at a level that is within the common range of fees billed by a majority of dentists for a procedure in a given geographic region

Included: Adult/Child: $1795 Copay

Prepaid ortho and/or vision plans can be added at noadditional cost by requesting it at the time of theemployer application submission. PPO ortho option isalso available for additional premium—plans P1000,P1500 & P2000

HMO No Waiting Period PPO 12 Month waiting period for major services.

Employees will receive credit for timecovered under this employer's prior plan.

Waiver of major services wait is available togroups with at least 12 months of comparable coverage with a prior carrier.There is a 5% load to rates to waive thewaiting period

PPO: If less than 12 months in business, prior approval requiredfrom Golden West.

HMO: Cosmetic/Elective benefit rider available for additional cost.See brochure Exhibit E for benefits and coverages.

HMO: Each family member may now select their own dental,orthodontic and vision provider. Up to 3 providers per family (3 general dentists, 3 orthodontists, and 3 vision providers).

Golden West PPO plans are underwritten by UNICARE: GoldenWest / WellPoint Network.

N/A



HMO

PPO

Indemnity

Standalone DHMO or PPO:Employer can contribute 0-49% ofemployee’s monthly premiumDual Choice:Employer can contribute 0-74% ofemployee’s monthly premium

Voluntary

Voluntary

Min. 2

N/A

N/A

N/A

PPOOnly

5-124

25% orMin. 5

N/A

N/A

N/A

Dual Op.7-124

HMO: Min. 2PPO: 25% or

Min. 5

N/A

N/A

N/A

DHMOOnly2-124

◆◆ 75%

N/A

100%

N/A

PPOOnly

10-124

◆◆ 75%

N/A

100%

N/A

Dual Op.10-124

◆◆ 75%

N/A

100%

N/A

Non-Voluntary



DUAL OPTION (MIX AND MATCH)Boxes containing a number indicate that these coordinate plans offered by this carrier can be written togetherto create a dual option package. The number indicates the minimum enrollment required on each of thecoordinate plans. Blank boxes indicate which plans cannot be written together


PRODUCTS OFFERED







153


Dental

Customer Service, Member Service,& Claims

Fax (Add-ons/Deletes)

All Counties except: Alpine, Amador, Calaveras, Colusa, Del Norte, Glenn, Inyo, Imperial, Kings, Lake, Lassen, Mariposa,Mendocino, Modoc, Mono, Napa, Nevada, Plumas, San Benito,Shasta, Sierra, Siskiyou, Tehama, Trinity, and Tuolumne

All Counties

N/A

Yes

866-249-2382

Health Net

Health Net

* Groups must have at least 2 eligible employees enrolling for a dual option with a minimum of 1 active employeeenrolled on the DPPO plan and 1 active employe enrolled on the DHMO plan. The total enrolled population mustmeet or exceed 75% of the group's total eligible employees.




NOTE: DHMO plans may not be available in all zip codes within a county. Check with your Word & Brown representative to confirm if coverage is availablefor your group location.

Health Net Dental HMO products are provided by Dental Benefit Providers of California, Inc., (“DBP”) and Health Net Dental PPO and indemnity productsare underwritten by Unimerica Insurance Company (together, “the DBP Entities”). Obligations of DBP and Unimerica Insurance Company are not theobligations of or guaranteed by Health Net, Inc. or its affiliates

1 Plans also are available on a voluntary basis for DHMO if participation is less than 50%, or contribution is less than 50%, or no prior group dentalcoverage

2 Voluntary DPPO rates are available to groups with less than 50% contribution or who do not have proof of prior coverage

916-935-4420

HMO Group Size PPO Indemnity

2-50 2-50

Employer-Paid:HN Plus 150-S

1

HN Plus 225-S 1

N/A

PPO Network

Group Size

DPPO allowed in all states; DHMO coverage is available inCalifornia only

51%

PPO Only

CA Employer Zip Code

Refer to dental underwriting guidelines for more info

HMO Network

DE

NT

AL

2-50 2-50

Voluntary:HN Plus 150(V)-S

1

HN Plus 225(V)-S 1

2-50 2-50 2-50 2-50 2-50 2-50

Employer-Paid and Voluntary 2:PPO Plus D5075-196-1000-SPPO Plus D5075-196-1500-SPPO Pref Value D5075-185-1000-SPPO Pref Value D5075-185-1500-SPPO Value D5075-185-1000-SPPO Value D5075-185-1500-S

HN Plus150-S

HN Plus225-S

HN Plus150(V)-S

HN Plus225(V)-S

PPO PlusD5075-196-

1000-S

PPO PlusD5075-196-

1500-S

PPO PrefValue

D5075-185-1000-S

PPO PrefValue

D5075-185-1500-S

PPO ValueD5075-185-

1000-S

PPO ValueD5075-185-

1500-S

HN Plus 150-S ● ● ● ● ● ● ● ● ●

HN Plus 225-S ● ● ● ● ● ● ● ● ●

HN Plus 150(V)-S ● ● ● ● ● ● ● ● ●

HN Plus 225(V)-S ● ● ● ● ● ● ● ● ●PPO Plus D5075-196-1000-S ● ● ● ● ● ● ● ● ●

PPO Plus D5075-196-1500-S ● ● ● ● ● ● ● ● ●

PPO Pref ValueD5075-185-1000-S ● ● ● ● ● ● ● ● ●

PPO Pref ValueD5075-185-1500-S ● ● ● ● ● ● ● ● ●

PPO Value D5075-185-1000-S ● ● ● ● ● ● ● ● ●

PPO Value D5075-185-1500-S ● ● ● ● ● ● ● ● ●


Choice of $1000 or $1500 orthodontic lifetimemaximum for children and adults. Available togroups with 10 or more enrolled employees or forgroups of 2-9 enrolled employees with proof ofimmediately prior indemnity orthodontic coverage

PPO

Employees

Dependents

Employees

Dependents

Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*








154

Dental

Yes—available when Health Net is the sole carrier and75% of the eligible employees enroll. The DE-6 and/orpayroll must clearly define the class of employeeswhich may be selected from (i.e. carved out) the entiregroup.

Same as above

Same as hourly/salary above

2 active employees

DHMO2-50 (Vol.)

HMO

2-50

1 Year

No

DHMO2-50

Min. 2

N/A

◆ 50%

N/A

2

N/A

50%

N/A

HMO No Waiting Period

PPO No Waiting Period

All employees (except owners or 1099 employees) mustbe covered by Workers' Compensation.

Voluntary rates apply to all DHMO and DPPO groups with noprior dental coverage regardless of the employer contribution oremployee participation.






Yes

Yes—if the group first meets AB1672 and 1099 employee isaffiliated with group long enough to be tied to company througha federal tax return & can meet the definition of a full-timeemployee. This can be demonstrated in the form of oneSchedule C and Form 1099-Misc from the most recent year.

No

Yes

Yes—reconciled

DHMO N/A

DPPO Out-of-network claims are paid based on the 80th percentile of UCR

DPPO2-50

◆ 75%

N/A

75%

N/A

PPO

2-50

1 Year

No

Group Size

Rate Guarantee


DHMO2-50

DPPO2-50

Call your Word & Brown representative for details on two employer-paid and two voluntary Health Net vision PPO plans.

50%

N/A

N/A

50%

N/A

N/A

HMOHN Plus 150(V)-S and HN Plus 225(V)-S: $1695 Copay for adults and children




PRODUCTS OFFERED







EPO Network

155


HMO Network

DE

NT

AL

SmileSaver Plan 1000 & 3000: All Counties

Plan 3500: All Counties

Plan 4000 & 5000: All Counties

Yes




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

PO Box 82520Lincoln NE 68501877-203-0036Fax 402-467-7336

SmileSaver SmileSaver Attn: Claims Dept. PO Box 30920 Laguna Hills, CA 92654 800-880-1800

Fax (Add-ons/Deletes)HSA California 866-251-4724

51%

All are allowed except Hawaii

PPO and EPO

It is based on the Employer zip

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 3500, and PPO 4000 & 5000WITHOUT Ortho

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

■ Voluntary 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 3500 2-50 Plan 4000Plan 5000

2-502-50

* Plan 3000 also is 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 1000 & 3000:SmileSaver Dental

PPO Network

Plan 3500: First Dental Health Network

Plan 4000 & 5000:Ameritas PPO

Employees

Dependents

Employees

Dependents

Employees

For Dependents

% of Total Cost:

RATING INFORMATION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE



CARVE OUTS*



Group Size

Rate Guarantee



156



2-50

2-50

2-50

12 Months

No


0%

0%

0%


0%

0%

◆◆ 100%

0%

0%

0%

0%

0%

50% of employee only premiumfor lowest cost plan offered

◆◆ 70%

0%



Union/Non-union?

Minimum group size

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

Are Commission-Only employees allowed?Yes, if on DE-6 and showing at least minimumwages and withholdings




DE-6 statement required?Yes


HMO N/A

EPO Plan 3500 - Out of network claims are paid based uponthe 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.

HMO N/A

EPO & PPO For groups with 10 or more employees,the 12 month waiting period for majorservices will be waived for individualswho were enrolled under this employer’scomparable group dental plan for 12months or more. All new hires andgroups without prior comparable dentalcoverage are subject to the waitingperiod. Credit will be given for time onthe prior plan. If orthodontia was coveredon comparable prior plan, credit will begiven toward the 24 month ortho waitingperiod.


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


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.




California DHMO Counties:

Boxes containing a number indicate that these coordinate plans offered by this carrier can bewritten together to create a dual option package. The number indicates the minimum enroll-ment required on each of the coordinate plans. Blank boxes indicate which plans cannot bewritten together


PRODUCTS OFFERED









PPO Network

Indemnity Network

157


DHMO Network

DHMO—DeltaCare® USA eligible zip codes

PPO—Delta Preferred Counties

FFS—Delta Premier (all counties)

DeltaCare® USA

Delta PPOPPO

*

FFS

2-50 PPO

Customer Service CenterKaiser Permanente Choice Solution800-580-9626


Commissions800-542-4218, Ext. 4390

ClaimsCHOICE Administrators®

721 South Parker, Suite 200Orange, CA 92868

Prepaid/DHMO Group Size

PPO Group Size


2-50 FFS

* PPO—only available if employee resides in PPO plan service areaFFS—only available to employees outside PPO plan service areaDHMO—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

DE

NT

AL

Employees

Dependents

Employees

Dependents

Are Commission-Only employees allowed?Yes—if on DE-6 and showing at least minimum wages and withholdings




DE-6 statement required?No—payroll OK

Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*


DHMO






Group Size

Rate Guarantee


PPO

FFS


158


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%

PPO Delta-approved fee schedule

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

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




These coordinate plans offered by this carrier can be written together to createa dual option package.


PRODUCTS OFFERED







159


SafeGuard DentalVisit www.safeguard.net

MetLife DentalVisit www.metlife.comAny PPO Plan ●

Dual Choice requires a minimum group size of 10 eligible with a minimum combinedparticipation of 7 employees with at least 5 employees enrolled on the PPO and 2employees enrolled on the DHMO.

Co-Insurance Levels AvailableSGX50*SGX85*SGX100SGX150ASGX185ASGX225SGX245SGX290Standalone & dual optionplans available

All Counties except: Alpine, Amador, Butte, Calaveras, Colusa, Del Norte,Glenn, Inyo, Imperial, Kings, Lake, Lassen, Mariposa, Mendocino, Modoc,Mono, Napa, Nevada, Plumas, San Benito, Shasta, Sierra, Siskiyou,Tehama, Trinity, and Tuolumne

All Counties

N/A

DHMO: Small Group: 90% min must reside in CA Large Group: Done on a case by case basis and must go through underwriting.

PPO: No requirement

California Prepaid DHMO Counties:




Prepaid/DHMO PPO/Indemnity

HMO Network

PPO Network

Member Services800-275-4638

[email protected]

ClaimsMetLife Dental ClaimsP.O. Box 981282El Paso, TX 79998888-466-8673


Contributory & Non-Contributory availableon all SGX plans. *Plan available to large group only (51+)

In-network100/90/60100/80/50100/80/50100/80/50

Out-of-network100/80/50100/80/5080/80/5080/60/40

Deductibles Available$50 In/Out (Waived for Preventative Services)

CYM Available$1,000, $1,500 & $2,000

Ortho Available$1,000 & $1,500

Any DHMO Plan

SafeGuard VisionVisit www.safeguard.net

Vision Network

Yes—PPO: National NetworkDHMO: Texas and Florida

Endo, Oral & Perio Services Available in Basic or Major Services.Other Co-Insurance Levels, Deductible, CYM & Ortho options available. Call your Word & Brown representative

DHMO: Networks in CA, TX & FLPPO: All states eligible

DHMO Plans: TX & FLPPO Plans: All

California Employer Zip Code

No

DE

NT

AL

EmployeesFor Dependents% of Total Cost:

DHMO 50% / Min. 5PPO 75% / Min. 2Dual Option 10 eligible / Min. 7 (Min. 2 on HMO & 5 on PPO)Vision 75% / Min. 5


RATING INFORMATION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE



Union/Non-union?

Minimum group size

CARVE OUTS*






Group Size

Rate Guarantee



160

2000 Calendar Year Maximum, 70th, 90th and 99th UCRand Maximum Allowable Charge (MAC) options areavailable. Call your Word & Brown representative forquote.

Dental rates are available on either 3 tier or 4 tier basis.

Yes†

Yes†

Yes†

PPO - 2 enrolling employeesDHMO - 5 enrolling employeesDual-Option - 10 eligible, 7 enrolling employees 5 onPPO and 2 on HMO0

N/AN/A

PPO

Min. 2

1 Year*

No






Yes

No

Dental offices and dental labs

Yes (Vol. PPO or Vol. DHMO)

No

DHMO N/ADPPO Southern California: 80th percentile of HIAA

Northern California: 80th percentile of HIAACan quote 70th, 90th and 99th percentile of HIAA and MaximumAllowable Charge (MAC). Call your Word & Brown representativefor details

DHMOIncluded - Child/Adult: $1,450 - $2,095 Copay

Indemnity-based orthodontic options (maximum$1000 or $1500 per calendar year) available for adultsand children with a minimum of 25 employeesenrolled in the PPO. Minimum group size is 5 withproof of immediate (no lapse) prior orthodonticindemnity coverage.

PPO

Dual Option

Min. 7

1 Year*

No

Group Size

Dental Rate Guarantee


2 and above

† MetLife must be the only carrier and 100% of eligible carveout population must enroll

* Except for DHMO plans - large group (51+) have a 2 year rate guarantee


DHMO Below 50% / Min. 5PPO Endo/Oral/Perio in Basic/Class II - 40% / Min. 5

Endo/Oral/Perio in Major/Class III - 30% / Min. 5

Dual Option DHMO & PPO w/Endo/Oral/Perio in Basic/Class II - 40% / Min. 7 (Min. 2 on HMO & 5 on PPO)

DHMO & PPO w/Endo/Oral/Perio in Major/Class III- 30% / Min. 7 (Min. 2 on HMO & 5 on PPO)

DHMO No waiting period

PPO Contributory - No waiting period (If groupwants to include a waiting period, call yourWord & Brown representative for a customquote.)Non-contributory - 12 month waiting periodon major services. Credit given with priorcoverage. If group wants no waiting period,call your Word & Brown representative for acustom quote

DHMO

Min. 5

1 Year*

No






PRODUCTS OFFERED


California POS Counties:







161


EPO Network

Principal Dental Series II (PDS II)Group SizeEPO, PPO or POS

Dual Choice with PPO: Available for groups of 10+ lives through the localsales office. First Dental Health

PPO NetworkThe Principal Plan Dental

Indemnity NetworkN/A

3-150

Customer & Broker Services949-553-1616

Adds/TermsFax 949-553-1898

Commissions800-388-4793

BOR ChangesFax 515-235-5538

Claims800-247-4695

Yes—contact your Word & Brown representative

Contact your Word & Brown representative. If quoting EPOor POS, all employees must be in California

All states available through Request-a-Quote. Contact your Word & Brown representative

PPO & Indemnity—contact your Word & Brown representative



Alameda, Butte, Contra Costa, El Dorado, Fresno, Imperial, Kern, Kings, Los Angeles,Madera, Marin, Mendocino, Merced, Monterey, Napa, Orange, Placer, Riverside,Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San LuisObispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma,Stanislaus, Sutter, Tulare, Tuolumne, Ventura & Yolo

All Counties

Alameda, Butte, Contra Costa, El Dorado, Fresno, Imperial, Kern, Kings, Los Angeles,Madera, Marin, Mendocino, Merced, Monterey, Napa, Orange, Placer, Riverside,Sacramento, San Bernardino, San Diego, San Francisco, San Joaquin, San LuisObispo, San Mateo, Santa Barbara, Santa Clara, Santa Cruz, Solano, Sonoma,Stanislaus, Sutter, Tulare, Tuolumne, Ventura & Yolo

California Indemnity Counties: N/A

POS NetworkPrincipal POS

DE

NT

AL

Employees

For Dependents

% of Total Cost:

Employees

Dependents






RATING INFORMATION

PARTICIPATION

Contributory

Voluntary

GROUP SIZE

GROUP SIZE



Union/Non-union?

Minimum group size

CARVE OUTS*


Dental - 10 enrolled lives for child ortho, 25 lives foradult or adult/child ortho

Voluntary Dental – Contact your Word & Brown representative






Group Size

Rate Guarantee



162



50th percentile60th percentile70th percentile75th percentile80th percentile

85th percentile 90th percentile95th percentile99th percentile

Yes

No

Yes

Yes

No

25%

N/A

75%

50%

100%

0%

N/A

Non-contributory

50–99%

0%

N/A

Contributory

0-49%

0%

N/A

Voluntary

Yes

Yes

Yes

10 enrolled lives

Benefit Waiting Period will not apply to Preventativeservices. You may elect a benefit waiting period forBasic services, Major services and Additional BenefitRiders.

1. For Retiree coverage, please contact your Word & Brown representative.

2. Annual enrollment period options are available.

3. Domestic Partner coverage is available.

4. Additional Benefit Riders are available.

5. No out of network for EPO and POS plans.

6. For groups over 150 lives, please contact your Word & Brown representative.

7. 3 & 4 life groups must quote 2 or more coverages.

8. Voluntary coverage is not available for groups under 10 lives.

Employees

Dependents

Non-Contributory

100%

50%

Employees

Dependents

3-150 employer paid 10-150 voluntary

Voluntary w/o prior<20 lives: 1 year>20 lives: 1 or 2 year

Dental or Vol w/prior<10 lives: 1 year>10 lives: 1 or 2 year

Yes

3-150 employer paid10-150 voluntary

3-150 employer paid10-150 voluntary

163







PRODUCTS OFFERED









HMO Network

PPO Network

Member Support,Customer Service, Commissions800-659-2223, ext. 0-82149

ClaimsP.O. Box 82510Lincoln, NE 68501800-497-7044


N/A

N/A

All Counties

Indemnity3-19*

N/A

Yes

No minimum

All states allowed

Indemnity with nationwide passive PPO

Rates are based on the firm’s home office (i.e. wherebilled)

No

Ameritas PPO

Group Size

Plan A: 100/80/50$1000 max., $50 deductible (3 per family)Vision Care option available

Plan B: 100/80-90/100 step-up in Basic/50$1500 max., $50 deductible (3 per family)Ortho benefit (all insureds)Vision Care option available * Large Group available upon request

DE

NT

AL

N/A

164


Employees

Dependents

Employees

Dependents

Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*







Group Size

Rate Guarantee








All insureds eligible. 50% to $1000 lifetime benefitwith a 24 month elimination period.

Yes

Yes

Yes

Down to 3 insured employees

3-19

25% of the total

cost

3-19

2 Years

No, some loaded industries considered higher risk

Yes

Yes

Yes

Yes

No

Indemnity:Insureds can choose any dentist with 90% of dentists in-network. Reimbursement outside of network is 80% ofUCR. Maximum Allowable Charge (MAC) option available for plans A and B and pays out-of-network dentist basedon Reliance Standard negotiated fee.

Groups of 3-5 eligible employees: 100%Groups of 6-9 eligible employees: all but one

Groups of 10-19 eligible employees: 75%

100% of eligible employees

12 month Basic Services elimination period waivedand credit given for calendar year deductibles paidfor groups that had a similar coverage in force for atleast 18 months prior to effective date. A rate factorof 10% is applied to takeover groups.

3-19





Boxes containing a number indicate that these coordinate plans offered by this carrier can bewritten together to create a dual option package. The number indicates the minimum enroll-ment required on each of the coordinate plans. Blank boxes indicate which plans cannot bewritten together


PRODUCTS OFFERED









HMO Network

Indemnity Network

165


N/A3-993-993-99

3-993-993-99

N/A

www.firstdentalhealth.comwww.ppousa.comwww.kernfmc.com

Silver

Gold *

SelectDent Group Silver PlanGold PlanPlatinum Plan

SelectDent Voluntary Standard PlanDeluxe PlanDeluxe Plus

N/A

N/A

All Counties

N/A

Yes—available for out of state employees of California based companies

Platinum *Standard *Deluxe *

HMO Group Size

PPO Group Size*


* Groups of 100+ call your Word & Brown representative for a custom quote

Silver Gold Platinum Standard Deluxe

UCR Plans Available

* All plans require three eligible employees with at least three enrolling in Voluntary and at least 75% enrolling in Group plan

Group Plans Voluntary Group Plans

Customer Service & Bilingual Support866-545-4500

Websitewww.healthedgeinc.comwww.healthedgeonline.com (user ID needed)

Broker Sales & Commissions866-616-4888 [email protected]

Claims and EligibilityHealthEdge Administrators, Inc.PO Box 11210Bakersfield, CA 93389866-545-4500Fax 661-616-4850


California Employer Zip

Deluxe/Deluxe Plus (UCR)

PPO Network

50%

All None

Deluxe Plus

Deluxe Plus *

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

* * * * *

Check with your Word & Brown representative to confirm if coverage is availablefor your group location.

DE

NT

AL


No Waiting Periods on any plans effective 04/01/07

No

Yes—as long as they work full-time and exclusivelyfor one employer. Must be approved by HealthEdgeprior to case submission

Yes

Yes

No (but we reserve the right to request one)

Employees

Dependents

Employees

Dependents






RATING INFORMATION

PARTICIPATION

Contributory

Non-Contributory

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?Yes

Minimum group sizeGroup Plan: 3 active employees with at least 75%enrolling

Voluntary Plan: 3 active employees with at leastthree enrolling

CARVE OUTS*

HMO






Group Size

Rate Guarantee

Renewals


PPO

Voluntary


166



3-99

12 Months

12 Months

No

SelectDent Voluntary Deluxe and Deluxe Plus:Out of Network claims paid at 80th percentile ofIngenix MDR

SelectDent Silver, Gold, Platinum & Standard:Out of Network claims based on the PPO FeeSchedule

N/A

Group

0%-50% of the lowest premium

N/A

N/A

Voluntary

0%-100%

N/A

N/A

Dependent children to age 19 (to age 23 for full timestudent). Services paid at 50% to a lifetime maximum of$1000 on Gold Plan ($350 cym) or $1500 on Platinum Plan($500 cym).

Group Voluntary

Min. 3

◆100%

N/A

◆3 Life

N/A

Min. 3

◆75%

N/A

◆3 Life

N/A

Deluxe ($400 cym) & Deluxe Plus ($700 cym).

Employees

For Dependents

% of Total Cost:

IndemnityDental PPO Plan Group (Gold & Platinum) UCR availableVoluntary (Deluxe & Deluxe +)


1) Three life groups with related employees require home office approval

2) Husband/Wife groups require a minimum of four to enroll

3) 5% discount when enrolling in dental and vision together


DMO Network

DPO Network

Indemnity Network

SmileSaver Dental Plan

PPO USA

HMO Network

PPO Network



PRODUCTS OFFERED

167


COVERAGE AREA


Boxes containing a number indicate that these coordinate plans offered by thiscarrier can be written together to create a dual option package. The numberindicates the minimum enrollment required on each of the coordinate plans.Blank boxes indicate which plans cannot be written together

Choice+ Indemnity

Customer Service, Member Service & CommissionsSmileSaver ClaimsPO Box 30920Laguna Hills, CA. 92654800-880-1800Choice+ ClaimsSecurity LifePO Box 1527Latham, NY 12110800-300-9566

Group Billing & EligibilityHMO—SmileSaver 800-750-4303PPO & Dual Option—Kelsey National 800-366-5656 x3

Fax (Add-ons/Deletes)SmileSaver 949-360-3695PPO/Dual Option 310-391-6534

2-999 2-9992-999 2-999

3-9993-9993-999

PPO Opt. 18

PPO Opt. 25

DHMO3000

*

*

DHMO1000

DHMO2000

* For employer sponsored dual option, group must have at least 2 enrollees on HMO and 3 enrollees on PPO or indemnity. Group must meet regular participation requirements. (see next page for details).

† If voluntary dual option, no minimum group size or participation requirement.Minimum of 1 on PPO and 2 on DHMO.

*

*

*

*

* Employer sponsored dual option requires a minimum of 5 enrollees (2 on the HMO and 3 on the PPO)† These plans also are available on a voluntary basis.

Choice+ PPO Opt. 18Choice+ PPO Opt. 25Choice+ PPO Opt. 26

DHMO 1000* DHMO 2000 †

DHMO 3000 †

SM 600 (Voluntary)

DHMO3000 Vol.

DHMO2000 Vol.

Covered Zip Codes: 90000-90299, 90500-90669, 91200-91399, 91600-91899, 92000-92099, 92500-92699, 92800-92899, 93000-93099, 93500-93599, 93100-93499, 93900-94299, 94800-95299, 95600-95899

All Counties

All Counties

California Prepaid DHMO Counties:




SM 600

3-999

PPO Opt. 26 * * *Indemnity * * *

†

†

†

†

†

†

†

†

Prepaid/DHMO Group Size

PPO Indemnity Group Size







Yes—Employer Sponsor minimum of 3 employees underIndemnity/PPO. Voluntary groups minimum of 1 under theIndemnity/PPO.

There cannot be more than 10% employees out-of-state

Contact your Word and Brown representative

The plan offering is the same as selected by the employer

They are rated the same as their employer in California

N/A

DE

NT

AL

168


Employees

Dependents

Employees

Dependents

DHMO No Waiting Period PPO 12 Month Waiting Period. Waiver available for

groups of 10 or more employees who were enrolled under the employer’s prior dental plan. The insured employees will receive credit for the time covered under the employer’s prior dental plan toward total or partial satisfaction of the major and/or ortho waiting period. (Proof of prior coverageis required.)






RATING INFORMATION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*





Group Size

Rate Guarantee


Dual Option


2-999; Stand alone DHMO 1000: 2-999

1 Year (2 years with approval)

No

Choice Plus plans no longer have a $22 admin fee.

DHMO members must use panel provider. Family members can use up to3 dental offices.Copays in DHMO brochure are for services performed by a panel generaldentist. If a panel specialist is used, the copays in subscriber contractapply.DHMO application and payment must be received by the 17th for 1st of thefollowing month effective date.Precious metals for restorative services, if used, will be charged to theDHMO memberSM 10 Vision Plan is included on DHMO. Buy-up SM 30 Vision is availablefor PPO enrollees of dual option group on a voluntary basis for $1 perfamily unit.

PPO/Indemnity: No DHMO: Yes

PPO/Indemnity: No DHMO: Yes

PPO/Indemnity: Yes DHMO: No

Yes

DHMO: No PPO & Indemnity: Yes

DHMOSM 600: Adult $2400 Copay/Child $2200 Copay* All other DHMOs: Adult $1950 Copay/Child $1600 Copay*

PPO

DHMO 5-7

2-999

75%

N/A

N/A

◆ 100%*

N/A

DHMO 2000/30008-99

DHMO 10-999

◆ 75%

N/A

PPO Indem.

3-7

◆ 100%*

◆ 50%

PPO Indem. 8-999

◆ 75%

◆ 50%

SM 6005-999

Min. 2

N/A

DHMO Vol.2-999

N/A

N/A

N/A

◆100%*

N/A

◆ 75%

N/A

◆ 100%

◆ 100%

◆ 100%

◆ 100%

N/A

N/A

Yes

Yes

Yes

2 for standalone DHMO 1000;5 for Dual Choice and standalone DHMO plans

Optional: Adult $2400 Copay/Child $2200 Copay

* Phase 1 ortho treatment not covered to include: extractions,study, models, tracings & photographs.† If employer elects Indemnity ortho, 100% of PPO/Indemnityenrollees with children must participate. There is a 24 month orthowait except for 10+ groups with takeover.

Indemnity




Standalone PPO or Dual Option – Employer may elect one of twoortho options:

1) DHMO ortho—Adult $1950 Copay/Child $1600 Copay* 2) Indemnity ortho—Child only: 50% - $500 maximum

per calendar year with lifetime maximum of $1000†

DHMO N/A

PPO & Indemnity Out of network claims are paidbased on the 80th percentile of MDR

Employees

For Dependents

% of Total Cost:


169

HMO Network




PRODUCTS OFFERED

Is Coverage Offered for Out-of-State employees? What plans (or plan types, such as PPO, Indemnity,etc) are offered for Out-of-State employees?





Customer Service, Member Service,Commissions800-228-3384

ClaimsHMO Claims:PO Box 25181, Santa Ana, CA 92799-5181800-622-6389


Alameda, Alpine, Amador, Butte, Calaveras, Colusa, Contra Costa, Del Norte, El Dorado,Fresno, Glenn, Humboldt, Imperial, Inyo, Kern, Kings, Lake, Lassen, Los Angeles,Madera, Marin, Mariposa, Mendocino, Merced, Modoc, Monterey, Napa, Nevada,Orange, Placer, Plumas, Riverside, Sacramento, San Benito, San Bernardino, SanDiego, San Francisco, San Joaquin, San Luis Obispo, San Mateo, Santa Barbara, SantaClara, Santa Cruz, Shasta, Sierra, Siskiyou, Solano, Sonoma, Stanislaus, Sutter,Tehama, Trinity, Tulare, Tuolumne, Ventura, Yolo & Yuba

HMO: No

SignatureValue SM

*Plan 140 ‡

*Plan 142 ‡

*Plan 144 ‡

*Plan 146 ‡

2-50 2-50 2-502-50

PacifiCare Dental HMO

California HMO Counties:*

* Plans quoted on the Word & Brown system ‡ Available as a voluntary plan. Not quoted through the Word & Brown system.


NOTE: Plans may not be available in all zip codes within a county. Check with your Word & Brown representative to confirm if coverage is available for yourgroup location.

N/A

PPO

CA Employer Zip code

None

DE

NT

AL

NOTE: All HMO plans can be sold as voluntaryor contributory and the rates are the same

• Offers two plan options (i.e., a high and low deductible PPO, or an Indemnity and a PPO) for eligible groups

• Access to our national PPO network of 113,000 providers• Available to groups with 10+ enrolled employees• Available combinations:

HMO/PPOHMO/INOHMO/Indemnity

PPO/PPOPPO/INOHMO/Indemnity

Other combinations available upon request. Please contact your Word & Brown representative.

5 eligible enrolled

10 eligible enrolled

170



HMO No Waiting Period

*Only new hires and eligible employees not listed on the group'sprior carrier's billing are subject to a 12-month waiting period forMajor Services; however, waiting period may be waived for anyemployee upon proof of prior like coverage.


Employees

Dependents

Employees

Dependents






Employees

For Dependents

% of Total Cost:

RATING INFORMATION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*






Group Size

Rate Guarantee

Rates vary by


Yes

Yes

Yes

See Products Offered section on previous page

No

Yes—no more than 25% of group can be 1099

No

Yes

Yes—DE-6, 2 weeks payroll or prior carrier bill

N/A

Adult/Child: $1895 Copay

An employer must be actively engaged in business orservice for at least 6 weeks of the preceding calendar quarterand have at least 2, but no more then 50 permanent, active,full-time eligible employees during this period.

Employees declining coverage must sign the Refusal ofEmployee and/or Dependent Coverage form. Not availablefor voluntary.

2-50

N/AN/A

25%†

2-50Voluntary

No employercontribution

required*

EmployeesFor Dependents% of Total Cost:*If employer contributes less than 50%, the group is considered voluntary.†Must meet participation requirement

2-50HMO

◆◆ 75%

N/A

2-50 HMO(Vol.)

Min. 2

N/A

100%

N/A

100%

N/A

For all plans – Orthodontic treatment must be provided by aPacifiCare Dental panel orthodontist. Orthodontic referralsmust be submitted by the patient’s assigned dental providerto PacifiCare Dental.


HMO

* Must meet participation requirement

Group Size

Rate Guarantee


HMO: 2-50

12 mo. rate guarantee

No

• Offers two plan options (i.e., a high and low deductible PPO, or an Indemnity and a PPO) for eligible groups

• Access to our national PPO network of 113,000 providers• Available to groups with 10+ enrolled employees• Available combinations:

HMO/PPOHMO/INOHMO/Indemnity

PPO/PPOPPO/INOHMO/Indemnity

Other combinations available upon request. Please contact your Word & Brown representative.



California DPO Counties:


PRODUCTS OFFERED







171


DPO Network

Customer Service, Member Service,Commissions800-896-4830

ClaimsUnitedHealthcare DentalAttn: Claims UnitP.O. Box 30567Salt Lake City, UT 84130-0567

Add-ons/Deletes FaxCall your Word & Brown representative

Yes—PacifiCare products: no more than 25% outside aPacifiCare state.

UnitedHealthcare products: no more than 25% of thegroup may be located in Vermont or Washington.

DPO P3350-VoluntaryDPO P3434DPO P3439DPO P3486DPO P4216DPO P4879DPO P4883DPO P4980

2-50 2-50 2-50 2-502-502-50 2-50 2-50

UnitedHealthcarewww.myuhcdental.comwww.employerservices.com

PPO or Indemnity

Dependent upon the type of plan and the state.

Out of state scenarios should be presented to the UHCSales Operation Specialist for guidance in rating questions

DPOGroup Size


All Counties

51% of the Eligible Employees. If there is not 51% of theeligible employees in any state, special guidelines apply.Contact your Word & Brown representative.


DE

NT

AL

5 eligible enrolled

10 eligible enrolled

Employees

Dependents

Employees

Dependents






RATING INFORMATION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?

Minimum group size

CARVE OUTS*




Group Size

Rate Guarantee



172



Yes

Yes

Yes

2

No

Yes—no more than 25% of the enrolled population

No

Yes

Yes—DE-6, payroll or prior carrier billing statement

Out of network option of 85th and 90th of HIAA

2-50 PPO

50%N/A

25%†

2-50PPO

◆◆ 75% of eligible employees, not less than 50%

N/A

2-50 PPO(Vol.)

Min. 2

N/A

100%

N/A

100%

N/A

PPO: 2-50

12 mo. rate guarantee

No

2-50Voluntary

EmployeesFor Dependents% of Total Cost:*If employer contributes less than 50%, the group is considered voluntary.†Must meet participation requirement

DPO No Waiting Period

*Only new hires and eligible employees not listed on the group'sprior carrier's billing are subject to a 12-month waiting period forMajor Services; however, waiting period may be waived for anyemployee upon proof of prior like coverage.




An employer must be actively engaged in business orservice for 45 days.

Employees declining coverage must sign the Refusal ofEmployee and/or Dependent Coverage form except forvoluntary options.


DPOChildren only - most common plan: $1,000 lifetimemaximum. These riders require minimum of 10eligible with 8 enrolled

50%50%50%

173


VISION

175





PRODUCTS OFFERED

California Vision Indemnity Counties:







Indemnity Network

Outlook Vision Services (National)www.outlookvision.com

The BEST Life Stand Alone Vision plans are available either as stand alonefor groups with 5 or more employees enrolling, or bundled with anotherBEST Life product for groups with 2 or more employees enrolling.

All counties

There is no minimum

Yes—BEST Life's Vision Indemnity plan is available to allstates in the country

There are no restrictions on which states can receive out-of-state coverage. BEST Life's Stand Alone Vision plan is available to all states within the country

Out-of-State employees can enroll on the Stand AloneVision plan, which is an Indemnity plan availablethroughout the United States.

Rates are based on the CA Employer Zip code

None

PlanExam/Lenses/Frames/ContactsPlan A 12/12/12/12 monthsPlan B 12/12/24/12 monthsPlan C12/12/24/24 monthsPlan D12/24/24/24 monthsPlans come with the choice of $0, $10 or $25 deductible, and contact lenses maybe covered in lieu of frames and lenses or in addition to frames and lenses.


Member Support, Customer Service & Commissions:[email protected]

BillingBEST Life and Health Insurance Co. 2505 McCabe WayIrvine, CA 92614-6243

ClaimsBEST Life and Health Insurance Co. P.O. Box 890Meridian, ID 83680800-433-0088Fax 208-893-5040Email: [email protected]


VI

SI

ON

176


Employees

Dependents

Employees

Dependents





Wage & tax reports required?

Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE



Union/Non-union?

Minimum group size

CARVE OUTS*






Group Size

Rate Guarantee



EmployerSponsored 5+

50%

N/A

N/A

Bundled: 2+, Stand alone: 5+

0%

N/A

N/A

Claims payments are based on a per service maximum

Voluntary Plans5+

Yes

60% participation of eligible employees. On groupswhere employer contributes 100% requires 100%

participation of eligible employees.

5+

1 year

N/A

20% participation of eligible employees

N/A

Yes—if group has a carve out in place with prior vision carrier

Yes—if group has a carve out in place with prior vision carrier

No

Minimum of 10 employees or more enrolling, if previously insured this way

There are no waiting periods for BEST Life's StandAlone Vision plan

No

These employees are not eligible unless written with medical

No

Yes

Yes—for groups enrolling less than 5 employees

177





PRODUCTS OFFERED








N/A

All Counties

51%

Yes

Hawaii not allowed

All PPO plans are available out of state

One rate for all in- and out-of-state employees

Employer paid groups from 2+, minimum participation 75%

Customer Service, Bilingual Support & Broker Services 877-601-9083

Commissions/BOR Changes 877-601-9083

Fax 714-619-4663


ClaimsNo claim forms are required for in-networkservices. Out of network form C-4669-61 isavailable at blueshieldca.com.

Mailing AddressBlue Shield of CaliforniaP.O. Box 25209Santa Ana, CA 92799-5209

Email: [email protected]


California Indemnity Counties:N/A

• Frequencies of 12/24/24, 12/12/24 and 12/12/12. • Lens benefits on a 24 month plan are available at 12 months with a qualifying change of prescription.• Frame allowances of $100, $120 and $130. The $130 plans include photochromic, progressive lens .

(no-line bifocal) and anti-reflective coating. • All plans include polycarbonate lenses for dependent children. • In and out of network benefits. • No waiting period, no claim forms for in-network services. • Eye exams are covered with a $0 copayment on all plans.• Voluntary vision for 10 eligible employees.• 3 hardware copays ($25, $15 and $0).• Low vision testing and equipment covered up to $1,000.• Plano sunglasses covered in lieu of lens and frames for those who have had PRK or LASIK surgery.

PPO Network

Indemnity Network

HMO Network

MESVision

N/A

N/A

VI

SI

ON

178


Employees

Dependents

Employees

Dependents






Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE



Union/Non-union?

Minimum group size

CARVE OUTS*






Group Size

Rate Guarantee

Rates vary byIndustry?


Yes—a minimum of 8 enrolled employees



8 enrolled for carve-outs; 2 enrolled for regular plans25%

0%

N/A

75%

N/A

No

No

None

Yes

No

2+ enrolled

2+

N/A

There are no waiting periods required by Blue Shieldof California. A group may impose its own waitingperiod

No

2+

2 Years for standalone

Retirees are not eligible for coverage

100%

N/A

179




Avesis California Insured Vision Plan Counties:

PRODUCTS OFFERED








Avesiswww.avesis.comPlan #905

N/A

Plan A -12/12/12/12

Exam - each 12 months

S/V, B/F, T/F lenses - each 12 months

Frames - up to $150 retail ($50 wholesale) - each 12 months

Contact lenses - $130 each 12 months in lieu of materials

Progressive Lenses - each 12 months -20% off UCR + $50 credit

All Counties

N/A

Minimum 5 enrolled for employer-paidMinimum 10 enrolled for voluntary

Yes—nationally

All states covered

Insured Vision Plan only

Single rate for all areas

Employer paid groups: minimum employer contribution of75% or 50% if tied to medical

Camden Broker Services 213-616-0640

Commissions 213-616-06403255 Wilshire Blvd., #1610Los Angeles, CA 90010

Avesis Claims/Member Services 800-522-0258

Avesis Eligibility Dept.-Adds/Terms Fax 213-384-0084

Avesis Customer Care Department Fax 866-871-1632

Avesis Insured Vision Plan: In-networkPlan B -12/12/24/12




Contact lenses - $130 in lieu of materials

Progressive Lenses - each 12 months -20% off UCR + $50 credit.

Plan C -12/24/24/24




Contact lenses - $130 each 24 monthsin lieu of materials

Progressive Lenses - each 24 months -20% off UCR + $50 credit

Insured Vision Plan Network

Indemnity Network

Exam: $45

SPECTACLE LENSES:Standard Single Vision $ 35.00Standard Bifocal $ 45.00Standard Trifocal $ 55.00Standard Lenticular $ 120.00Progressive $ 45.00Specialty Lenses Corresponding Standard Lens reimbursement

FRAME: $40.00

CONTACT LENSES:Elective $ 130.00Medically Necessary: $ 250.00

All reimbursement amounts listed above are up to the posted dollar amount.

LASIK:$150 plus 25% (In-network)$150 in lieu of all other services (Out-of-Network)

Avesis Insured Vision Plan: Out-of-network


The Camden Insurance AgencyVision Plan of AmericaAn affiliate of

The Avesis Insured Vision Plan is brought to you by CamdenInsurance, an affiliate of Vision Plan of America, and isunderwritten by Fidelity Security Life. Policy #VC-16; Form M9059 V

IS

IO

N

180


Employees

Dependents

Employees

Dependents






Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE



Union/Non-union?

Minimum group size

CARVE OUTS*






Group Size

Rate Guarantee



N/A

N/A

N/A

5 - employer-paid10 - voluntary

75% of employer-paid or 50% if tied to medical

0% for voluntary


N/A


N/A

No

No

No

Yes

No

5+ employer-paid10+ voluntary

5+ employer-paid10+ voluntary

Each 15 days

10+ voluntary

No waiting periodsNo pre-approvals*

*Except for medically necessary contact lenses

No

5+ employer-paid

2 years

The Camden Insurance AgencyVision Plan of AmericaAn affiliate of

Limitations: This plan is designed to cover eyeexaminations and corrective eyewear. It is alsodesigned to cover visual needs rather than cosmeticoptions. Should the member select options that are notcovered under the plan, as shown in the schedule ofbenefits, the member will pay a discounted fee to theparticipating Avesis provider. Benefits are payable onlyfor services received while the group and individualmember's coverage is in force.

Exclusions: There are no benefits under the plan forprofessional services or materials connected with andarising from: 1) Orthoptics of vision training; 2)Subnormal vision aids and any supplemental testing;3) Plano (non-prescription) lenses, sunglasses; 4) Twopair of glasses in lieu of bifocal lenses; 5) Any medicalor surgical treatment of eye or support structures; 6)Replacement of lost or broken lenses, contact lensesor frames, except when the member is normallyeligible for services; 7) Any eye examination orcorrective eyewear required by an employer as acondition of employment; 8) Services or materialsprovided as a result of Workers Compensation Law, orsimilar legislation, required by any governmentalagency whether Federal, State or subdivision thereof.

181




PRODUCTS OFFERED


www.vsp.com

Indemnity Vision and Indemnity Voluntary Vision







Vision coverage is available throughout the state

Yes—contact your Word & Brown representative

Customer & Broker Services949-553-1616

Adds/TermsFax 949-553-1898


BOR ChangesFax 515-235-5538

Claims800-247-4695

Less than 25% of group can reside outside of California

Vision is available in all states except Maryland and Vermont

Indemnity. Vision is not available in Maryland or Vermont.

Rates are based on CA employer zip code, with nodifference in rates for other locations

Yes—see Special Considerations

VI

SI

ON

182


Employees

Dependents





DE6 statement required?

Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Voluntary

GROUP SIZE

GROUP SIZE



Union/Non-union?

Minimum group size

CARVE OUTS*






Group Size

Rate Guarantee



Yes

Yes

Yes

10 enrolled lives

Yes

No

Yes

Yes

No

10-150

N/A

Waiting periods do not apply.

No

12 months

1. Contacts are only available if medically necessary.

2. Contact lens benefit is in lieu of the lens and frame,when contacts are chosen.

3. Annual enrollment period applies.

4. For groups over 150 lives, please contact yourWord & Brown representative.

5. Retirees are not eligible for coverage.

6. Members are eligible for a vision discount plan, theVSP Access Program, at no extra cost.

25%

N/A

25%

N/A

10-150

0 to 100%

0%

N/A

10-150

Employees

Dependents

Non-Contributory

100%

N/A

Employees

Dependents

183





PRODUCTS OFFERED








N/A

All Counties

90%

Yes

All states are allowed

All PPO plans are available out of state

One rate for all in- and out-of-state employees

No

Customer Service, Bilingual Support& Broker Services:800-880-1800



ClaimsSafeGuardVision Claims Dept.P.O. Box 8100Laguna Hills, CA 92654-8100


California Indemnity Counties:N/A

PPO Vision Plan OptionsV85D $25E/$0M - 12/12/24, $85 Frame Allowance, $25 Exams Copay/$0 Materials CopayV85D $10E/$25M - 12/12/24, $85 Frame Allowance, $10 Exams Copay/$25 Materials CopayV85C $25E/$0M - 12/24/24, $85 Frame Allowance, $25 Exams Copay/$0 Materials CopayV85C $10E/$25M -12/24/24, $85 Frame Allowance, $10 Exams Copay/$25 Materials CopayV125A $0E/$0M -12/12/12, $125 Frame Allowance, $0 Exams Copay/$0 Materials CopayV125A $10E/$25M -12/12/12, $125 Frame Allowance, $10 Exams Copay/$25 Materials CopayV125D $0E/$0M -12/12/24, $125 Frame Allowance, $0 Exams Copay/$0 Materials CopayV125D $10E/$25M -12/12/24, $125 Frame Allowance, $10 Exams Copay/$25 Materials Copay

* Range of plans from $30 to $125 retail frame allowance and Hardware Only plans available—ask your Word & Brown representative for details.

Vision Benefits● In and Out of Network Benefits● Ultraviolet protection as a standard benefit● Polycarbonate lens coverage for children● Plans available with progressive lenses—ask your Word & Brown

representative for details.● Plans available for groups as small as five● Voluntary or employer-paid plans● Two year rate guarantee● Extensive, fully credentialed, network of eye professionals contracted with

Ophthalmologists, Optometrists & Opticians. Contracted with all models of practice private, group & retail chains. Chains include Sears, JC Penney, selected Walmarts, Target & Sterling Optical.

● Laser vision correction discounts● Anything that is not covered at a co-pay is available at a 20% discount

PPO Network

Indemnity Network

HMO Network

SafeGuard

N/A

N/A

VI

SI

ON

184


Employees

Dependents

Employees

Dependents






Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE



Union/Non-union?

Minimum group size

CARVE OUTS*





Group Size

Rate Guarantee

Rates vary byIndustry?





5 enrolled 0%

0%

N/A

25%

N/A

No

No

None

Yes

No

5+

5+

N/A

There are no waiting periods required. A group mayimpose its own waiting period

No

5+

24 months

SafeGuard Vision PPO Network

100%

N/A




PRODUCTS OFFERED









PPO Network

Indemnity Network

185


HMO Network

N/A

Yes—as long as the company is based in California

Customer Service, BilingualSupport & Broker Services866-616-4888800-521-3605


Claims800-521-3605


Directory Informationwww.enrollwitheyemed/access or 866.723.0596

Employer Paid: minimum 75% of eligible Voluntary: No minimum participation required

None

The same plan is the same as the employers plan

Neither

See Certificate of Benefits for full guidelines, restrictions andlimitations

All

N/A

www.enrollwitheyemed.com/access

N/A

N/A


VI

SI

ON

Eye Examination Silver Gold PlatinumPlan #9657974 Plan #9657941 Plan #9657925

Frequency Once Every 12 Months Once Every 12 Months Once Every 12 MonthsCo-Pay $10 $10 $0

Eyeglass LensesFrequency Once every 24 Months Once Every 12 Months Once Every 12 Months

Co-Pay $20 $10 $0 Frames

Frequency Once every 24 Months Once Every 12 Months Once Every 12 MonthsCo-Pay $0 $0 $0

Employees

Dependents

Employees

Dependents

Are Commission-Only employees allowed?No

Are 1099 employees allowed?Yes—as long as they work full-time and exclusivelyfor one employer. Must be approved by HealthEdgeprior

Any ineligible industries?None


DE-6 statements required?No—but we deserve the right to request one

Employees

For Dependents

% of Total Cost:

RATING INFORMATION

PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE





Union/Non-union?Yes

Minimum group sizeGroup: A minimum of 75% of eligible employeesmust participate

Voluntary: No minimum participation required

CARVE OUTS*






Group Size

Rate Guarantee



186



2-99

See Brochure for pricing

No

2 years

NoneN/A

N/A

N/A

N/A

N/A

N/A

50% of lowest Premium

N/A

N/A

N/A

N/A

N/A 1) 5% discount when enrolling in dental and vision together

187




CA HMO Counties:

PRODUCTS OFFERED







Copayment plan M-Plus — unlimited benefit starting at$3.50/month

All counties

California only

No out-of-state coverage for HMO plan

No out-of-state coverage for HMO plan

N/A

N/A

N/A

Vision Plan of AmericaBroker Services/Member Eligibility Dept.800-400-4VPA (4872)

Commissions 800-400-48723255 Wilshire Blvd., #1610Los Angeles, CA 90010

Accounting/Billing Department 213-384-2600 (A-P Ext. 104) and (Q-Z Ext. 105)

Provider Relations Department 213-384-2600 Ext.103

Add-ons/Deletes800-400-4872, Ext 8Fax 213-384-0084

Website - Sales/Service/Infowww.visionplanofamerica.com

Low Cost


National Insured Vision PlanAvailable from CIA: Camden Insurance Agency

Visionplanofamerica.com/providers

All providers operate in a “privatepractice” setting

HMO Network

VI

SI

ON

Minimum 2 lives required

Plan 1 - (12/12/12/12)Plan 2- (12/12/24/12)Plan 3 - (12/24/24/24)

•Various copayment options•Standard $100 retail frame allowance•Stand alone or bundled with dental•No waiting periods•No claim forms•All plans include LASIK copayment plan(LASIK administered by QualSight)

•Contact lenses in addition to

Voluntary participation - 2+ livesEmployer paid participation - 2+ lives

Individual plans available - stand alone or bundled with dental

Full Service Bundled Dental/Vision PlansAvailable for groups and individuals. Single premiumplans include dental, vision and ortho

188


Employees

Dependents





Wage & tax reports required?

Employees

For Dependents

% of Total Cost:

RATING INFORMATION


PARTICIPATION

Contributory

Non-Contributory

GROUP SIZE

GROUP SIZE



Union/Non-union?

Minimum group size

CARVE OUTS*






Group Size

Rate Guarantee



N/A

N/A

N/A

2 - employer-paid2 - voluntary

50% of employer-paidor 0% for voluntary

No

No

No

Yes

No

HMO: 2+

HMO2+

N/A

No waiting periodsNo pre-approvals*No claim forms

*Except for medically necessary contact lenses

No

2 years

N/A

N/A

HMO

N/A

2+

Employees

Dependents N/A

2+

Limitations: This plan is designed to cover eyeexaminations and corrective eyewear. It is alsodesigned to cover visual needs rather than cosmeticoptions. Should the member select options that are notcovered under the plan, as shown in the schedule ofbenefits, the member will pay a discounted fee to theparticipating Avesis provider. Benefits are payable onlyfor services received while the group and individualmember's coverage is in force.

Exclusions: There are no benefits under the plan forprofessional services or materials connected with andarising from: 1) Orthoptics of vision training; 2)Subnormal vision aids and any supplemental testing;3) Plano (non-prescription) lenses, sunglasses; 4) Twopair of glasses in lieu of bifocal lenses; 5) Any medicalor surgical treatment of eye or support structures; 6)Replacement of lost or broken lenses, contact lensesor frames, except when the member is normallyeligible for services; 7) Any eye examination orcorrective eyewear required by an employer as acondition of employment; 8) Services or materialsprovided as a result of Workers Compensation Law, orsimilar legislation, required by any governmentalagency whether Federal, State or subdivision thereof.

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word & brown—broker's health plan reference guide for … · 2010-02-16 · the health...

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