Stanford University EPO Plan Group# 976109 Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix)

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Blue Shield of California Highlights:

A description of the prescription drug coverage is provided separately

Effective January 1, 2014 1

Preferred Providers $0 per individual/$0 per family $3,000 per individual/$6,000 per family None

2

Calendar Year Medical Deductible 2 Calendar Year Copayment Maximum LIFETIME BENEFIT MAXIMUM

Covered Services

Member Copayment

PROFESSIONAL SERVICES Professional (Physician) Benefits  Physician office visits (Includes Family Practice, General Practice, Internist,

Preferred Providers

1

$20 per visit

5

Pediatrician and OB/GYN)

  

5

Specialist office visit (Includes all other provider designations) CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic 3 procedures utilizing nuclear medicine (prior authorization is required) Other outpatient X-ray, pathology and laboratory (Diagnostic testing by

$50 per visit No Charge No Charge

providers other than outpatient laboratory, pathology, and imaging departments of 3 hospitals/facilities)

Allergy Testing and Treatment Benefits 5  Office visits (includes visits for allergy serum injections) Preventive Health Benefits  Preventive Health Services (as required by applicable federal law.) OUTPATIENT SERVICES Hospital Benefits (Facility Services) 4  Outpatient surgery performed at an Ambulatory Surgery Center  Outpatient surgery in a hospital  Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under "Rehabilitation Benefits")  CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital (prior

$20 per visit No Charge

$100 per surgery $100 per surgery No Charge No Charge

3

authorization is required)

 

Other outpatient X-ray, pathology and laboratory performed in a 3 hospital Bariatric Surgery (prior authorization required by the Plan; medically necessary

No Charge $100 per surgery

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services)  Inpatient Physician Services  Inpatient Non-emergency Facility Services (Semi-private room and board, 

and medically-necessary Services and supplies, including Subacute Care) Bariatric Surgery (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only)

Skilled Nursing Facility Benefits

No Charge $100 per admission $100 per admission

7

(Combined maximum of up to 100 prior authorized days per Calendar Year; semi-private accommodations)

 

Services by a free-standing Skilled Nursing Facility Skilled Nursing Unit of a Hospital

$100 per admission $100 per admission

EMERGENCY HEALTH COVERAGE 

 

Emergency room Services not resulting in admission (Copayment does not apply if the member is directly admitted to the hospital for inpatient services) (If ER services do not result in a direct admission the Calendar-Year Deductible does not apply) Emergency room Services resulting in admission (when the member is admitted directly from the ER)

Emergency room Physician Services

$100 per visit

$100 per admission No Charge

An Independent Licensee of the Blue Shield Association

surgery for weight loss, for morbid obesity only)

AMBULANCE SERVICES 

Emergency or authorized transport

$50

PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug A description of your outpatient prescription drug coverage is provided separately. If you do not have the separate drug summary that goes with this benefit summary, please contact your benefits administrator or call Customer Services. PROSTHETICS/ORTHOTICS  

Prosthetic equipment and devices (Separate office visit copay may apply) Orthotic equipment and devices (Separate office visit copay may apply)

No Charge No Charge

DURABLE MEDICAL EQUIPMENT  

MENTAL HEALTH SERVICES (PSYCHIATRIC)  

No Charge No Charge

Breast pump Other Durable Medical Equipment 8

Inpatient Hospital Services Outpatient Mental Health Services

CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)  

9

Inpatient Hospital Services Outpatient Chemical dependency and substance abuse services

HOME HEALTH SERVICES  

$100 per admission $20 per visit $100 per admission $20 per visit

10

Home health care agency Services Home infusion/home intravenous injectable therapy and infusion nursing visits provided by a Home Infusion Agency

OTHER 10 Hospice Program Benefits  Routine home care  Inpatient Respite Care  24-hour Continuous Home Care  General Inpatient care Chiropractic Benefits  Chiropractic Services (up to 20 visits per calendar year) Acupuncture Benefits  Acupuncture by a certificated acupuncturist (up to 20 visits per calendar year) Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy)  Office location Speech Therapy Benefits  Office location Pregnancy and Maternity Care Benefits  Prenatal and postnatal Physician office visits

No Charge No Charge

No Charge No Charge No Charge No Charge $20 per visit $20 per visit $50 per visit $50 per visit No Charge

(For inpatient hospital services, see "Hospitalization Services.")

Family Planning Benefits 11  Counseling and consulting 6  Elective abortion  Tubal ligation 6  Vasectomy Diabetes Care Benefits  Devices, equipment, and non-testing supplies (for testing supplies see

No Charge $125 per surgery No Charge $50 per surgery No Charge

Outpatient Prescription Drug Benefits.)



Diabetes self-management training (If billed by your provider, you will also be responsible for the office visit copayment)

5

$20 per visit

Benefits provided through BlueCard® Program, for out-of-state emergency and non-emergency care, are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider.

Care Outside of Plan Service Area 

Within US: BlueCard Program



Outside of US: BlueCard Worldwide

1 2

3

See Applicable Benefit See Applicable Benefit

Member is responsible for copayment in addition to any charges above allowable amounts. The copayment percentage indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield's allowable amount as full payment for covered services. Copayments marked with a "2" do not accrue to calendar-year copayment maximum. Copayments and charges for services not accruing to the member's calendar-year copayment maximum continue to be the member's responsibility after the calendar-year copayment maximum is reached. Please refer to Plan Contract for exact terms and conditions of coverage. Participating ambulatory surgery and non-Hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services or outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits.

4 5 6 7 8 9 10 11

Participating ambulatory surgery facilities centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital; with payment according to your health plan's hospital services benefits. Services provided by other than a Family Practice, General Practice, Internist, Pediatrician, or OB/GYN provider, the specialist office visit copayment of $50 per visit applies. Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Services may require prior authorization by the Plan. When services are prior authorized, members pay the preferred or participating provider amount. Mental health services are accessed using Blue Shield's participating providers. Inpatient services for acute detoxification are covered under the medical benefit; see hospitalization services for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's preferred providers. Out of network home health care, home infusion and hospice services are not covered unless pre-authorized. When these services are pre-authorized, the member pays the Preferred Provider copayment. Includes insertion of IUD as well as injectable contraceptives for women.

Plan designs may be modified to ensure compliance with federal requirements.

An Independent Licensee of the Blue Shield Association

ASO (1/14) ASO RO 081613

Stanford University Group# 976109, 976248

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Outpatient Prescription Drug Coverage (For groups of 300 and above)

Blue Shield of California Highlight:

3-Tier/Incentive Formulary $0 Calendar-Year Brand-Name Drug Deductible $10 Formulary Generic/$30 Formulary Brand Name/$75 Non-Formulary Brand Name Drug - Retail Pharmacy $20 Formulary Generic/$60 Formulary Brand Name/$150 Non-Formulary Brand-Name Drug - Mail Service

Covered Services

Member Copayment

DEDUCTIBLES (Prescription drug coverage benefits are not subject to the medical plan deductible.)

Calendar Year Brand Name Drug Deductible PRESCRIPTION DRUG COVERAGE

None

1, 6

Participating Pharmacy

Non-Participating Pharmacy Member pays 25% of billed amount plus a copayment of:

Retail Prescriptions (up to a 30-day supply) 2  Contraceptive Drugs and Devices

$0 per prescription

Not Covered



Formulary Generic Drugs

$10 per prescription

$10 per prescription



Formulary Brand Name Drugs

$30 per prescription

$30 per prescription

$75 per prescription

$75 per prescription

Mail Service Prescriptions (up to a 90-day supply) 2  Contraceptive Drugs and Devices

$0 per prescription

Not Covered



Formulary Generic Drugs

$20 per prescription

Not Covered



Formulary Brand Name Drugs

$60 per prescription

Not Covered

$150 per prescription

Not Covered

Brand Name copayment

Not Covered





3, 4

Non-Formulary Brand Name Drugs

3, 4

3, 4

Non-Formulary Brand Name Drugs

3, 4

Home Self Administered Injectable Drugs (up to a 30-day supply) 6  Home self administered injectable drugs

1 Copayments and charges for these covered services are not included in the calculation of the member's medical calendar-year copayment maximum and continue to be the member's responsibility after the calendar-year copayment maximum is reached. Please refer to the Plan Contract for exact terms and conditions of coverage. Please note that if you switch from another plan, your prescription drug deductible credit from the previous plan during the calendar year, if applicable, will not carry forward to your new plan. 2 Contraceptive Drugs and Devices covered under the outpatient prescription drug benefits will no longer require a copayment and will not be subject to the calendar-year brand-name drug deductible. However, if a brand-name contraceptive is requested when a generic equivalent is available, the member will still be responsible for paying the difference between the cost to the Plan for the brand-name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be covered without a copayment. 3 Selected formulary and non-formulary drugs require prior authorization by Blue Shield for Medical Necessity, and when effective, lower cost alternatives are available. 4 If the member requests a brand-name drug and a generic drug equivalent is available, the member is responsible for paying the generic drug copayment plus the difference in cost to Blue Shield between the brand-name drug and its generic drug equivalent. 5 Infertility drugs are covered up to plan payment maximum of $5,000 per lifetime 6 Home self-administered injectable drugs are covered only when dispensed by select pharmacies in the Specialty Pharmacy Network unless Medically Necessary for a covered emergency.

An Independent Member of the Blue Shield Association

5

Important Prescription Drug Information You can find details about your drug coverage three ways: 1. Check your Plan Contract. 2. Go to blueshieldca.com and log onto My Health Plan from the home page. 3. Call Member Services at the number listed on your Blue Shield member ID card. At Blue Shield of California, we're dedicated to providing you with valuable resources for managing your drug coverage. Go online to the Pharmacy section of blueshieldca.com and select the Drug Database and Formulary to access a variety of useful drug information that can affect your out-of-pocket expenses, such as:  Look up non-formulary drugs with formulary or generic equivalents;  Look up drugs that require step therapy or prior authorization;  Find specifics about your prescription copayments;  Find local network pharmacies to fill your prescriptions. TIPS! Using the convenient mail service pharmacy can save you time and money. If you take a consistent dose of a covered maintenance drug for a chronic condition, such as diabetes or high blood pressure, you can receive up to a 90-day supply through the mail service pharmacy with a reduced copayment. Call the mail service pharmacy at (866) 346-7200. Members using TTY equipment can call TTY/TDD 866-346-7197. Plan designs may be modified to ensure compliance with federal requirements.

ASO (1/13) RO 081913