The Power of BlueThe Power of Blue

Individual & Family Health Plans

Blue Cross• One of California’s largest Individual

healthcare coverage providers• Has served three generations• Has plans to protect your client’s health &

financial futures• Parent Company was named #1 on

Fortune magazine’s Most Admired Health Care Company List for an unprecedented 5th consecutive year

Individual & Family Health Plans

Individual & Family Health Plans

Portfolio effective 3/1/04 Portfolio effective 3/1/04

Pricing FeaturesPricing Features• Younger Spouse rating for couples and

families.

• Five-year age bands for 30 to 64 year-old rates.

• 9 Rating Areas more precisely match premiums to various regional medical costs.

Price & Benefit GuaranteePrice & Benefit Guarantee

A full six-months from the client’s

original effective date

Greater Share of Cost for Member =

Lower Premium

Greater Share of Cost for BCC =

Higher Premium & Richer Benefits

We offer clients choices!We offer clients choices!

22%

18%

18%

15%

15%

7%5%

Drugs, Medical Devices & Medical Advances (22%)

General Economic Inflation (18%)

Rising Provider Expenses (18%)

Government Mandates & Regulation(15%)

Increased Consumer Deman (15%)d

Litigation & Risk Management (7%)

Other (5%)

Factors Driving Rising Premium Costs 2001-2002

Source: PricewaterhouseCoopers, The Factors Fueling Rising Health Care Costs, April 2002

Individual & Family Plans from Blue Cross

Individual & Family Plans from Blue Cross

•Basic (Hospital) PPO: 2500 or1000

•PPO Saver

•PPO Share: 5000, 2500,1500,1000 or 500

•RightPlan PPO 40

•HMO or HMO Saver

Expanded EligibilityExpanded Eligibility

• Domestic Partner Coverage

– Declaration of Domestic Partnership filed with the California Secretary of State is required to enroll

– Submit with Individual Enrollment Application

PPO FeaturesPPO Features• First dollar coverage on

– Office visits, generic drugs, preventive care, the most used benefits

– Acupuncture visits on the PPO Share and RightPlans

– All except Basic (Hospital) PPO Plans

• Choice of coverage and providers– Cost savings through network providers

PPO Features, ContinuedPPO Features, Continued• No pre-authorization for most covered

services

• Annual out-of-pocket maximum – $3,500-$7,500 depending upon plan

– Combined In- and Out-of-Network

– Once met, plan pays 100% of eligible in-network medical costs

• Lifetime maximum up to $5 million

Annual Out-of-Pocket MaximumIn & Out-of-network Charges Combined

Plan Per Member (2-member maximum)Basic PPO 1000 $3,500Basic PPO 2500 $5,000PPO Saver $5,000PPO Share 5000 $7,500 PPO Share 2500 $7,500RightPlan PPO 40 $7,500PPO Share 1500 $6,000PPO Share 1000 $5,000

PPO Share 500 $5,000HMO Saver and Individual HMO $3,000

100% coverage of eligible medical costs in-network above the annual maximum out-of-pocket

Share of Cost DefinitionsShare of Cost Definitions

• Share of Cost = in-network amount member pays

• In-network cost is based on a negotiated fee rate.

• Deductible = Unless otherwise indicated, this is the amount the member pays before the Share of Cost. For a family contract, only 2 members must satisfy their individual deductibles.

Basic (Hospital) PPO 2500/1000 Share of Costs

• Deductible = $2500 or $1000• Hospital = 20% (Preferred Participating)• Professional Services (lab, x-ray, anesthesia,

surgeon, etc.) = 20% hospital only until out-of-pocket maximum is met.

• Office visits = no coverage until out-of-pocket maximum is met

• No Maternity• Available with or without $1000 Term Life

PPO Saver Share of Costs• Deductibles = $500 in-hospital; $5000 other covered

services• Hospital = 20% after $500 deductible• Professional Services =

– 20% after $500 deductible for in- and out-patient or Ambulatory Surgical Center services;

– 20% after $5000 deductible for all other covered services.– Provider discounts apply while member is meeting deductible.

• Office visits = First 4 child/2 adult visits @ $30 copay (deductible waived)

• No Maternity• Available with or without $1000 Term Life

PPO Share 5000/2500/1500/1000/500 Plans Share of Costs

• Deductible = $5000, $2500, $1500, $1000 or $500 depending on plan

• Hospital = 30% (Preferred Participating)• Professional Services = 30%• Office Visits = 30% (deductible waived)• Maternity = 30%

RightPlan PPOs Share of Costs

• Deductible = None• Office Visit = $40 copay• Hospital = 40% of negotiated fee plus $400

copay per day/4-day maximum copay per admission

• Professional Services = 40%• No Maternity

RightPlans Special Features

• Single Policy Coverage– No couple or family contracts – Each family member gets their own policy

• 3 Pharmacy Options– None (Lowest Price)– Generic Only (Lower Price)– Full Pharmacy (Low Price)

• No Maternity

HMO and HMO Saver Share of Cost

• Deductible = – None for HMO – HMO Saver has $1500 deductible for inpatient hospital

services & outpatient ambulatory surgical centers only• Office Visit = $10 Copay• Professional Services Out of hospital= $10 • Professional Services In-hospital

– No charge on HMO – HMO Saver subject to $1,500 deductible

Formulary Drug Share of Cost Retail or Mail Order (30-day supply)

Generic - $10 copay

Brand - $30 copay ($35 on PPO Share 5000)Subject to following Brand Deductibles:

Deductible$250$500$750

PlansPPO Share 1500/1000/500 and HMOsPPO Saver, PPO Share 2500, RightPlanPPO Share 5000

Non-Formulary Drug Share of Cost

Generic• 50% of drug costBrand Drugs with Generic Equivalent • Generic Copay + Cost Difference between

Brand & Generic after Brand Name Deductible is met

Brand Drugs without Generic Equivalent • 50% of drug cost after Brand Name Deductible

is met

Emergency Room Copay

• Emergency Services Defined– Appropriate treatments for a sudden, serious and

unexpected acute illness, injury, psychiatric or medical condition.

• If not admitted to hospital– Copay required in addition to the coinsurance

• Right Plan PPO 40 = $30 copay • All Other Plans = $100 copay• Coinsurance amount is the same as what the plan pays for

Professional Services

Preventive Care Share of Cost• PPO Plans (Deductible Waived)

– Routine mammogram, Pap, PSA tests ordered by a physician = 30% (20% on PPO Saver)

– Well Baby/Well Child = 40% (50% on PPO Saver) • Not covered on PPO Basic 1000 Plan

– HealthyCheck Center • $25 or $75 for Basic Screenings

• HMO Plans– $10 Copay

We Offer FamilyElectWe Offer FamilyElect• Based on needs, each family member can choose his

or her own plan (including RightPlan PPO 40)

• Family submits an application with one check for all premiums

• Once approved for coverage, the family can pay for everyone on one bill

Value-Added Programsfor all members

Blue Cross Healthy Extensions :• Discounts on a wide range of alternative health care and wellness products and services

through independent vendors. Blue Cross MedCall: • For reliable health care information from a registered nurse or one of 200 educational audio

tapes 24-hours a day.

Blue Cross BabyConnection : • Promotes early and regular prenatal care.

SM

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More Value-Added ProgramsPPO Members:• BlueCard Program is there for clients who travel to provide network savings

with more than 70% of doctors and 80% of hospitals in America.

HMO Members: • With DirectAccess providers, client can self refer to a Participating Specialty

Service Provider without a Primary Care Physician’s authorization

• With SpeedyReferral providers, clients get immediate referral for certain specialty consultations without prior authorization from the medical groups management committee

Payment & Billing• Initial Premium Payment Methods

– Checking Account Deduction – Credit Card (Visa, MasterCard or Discover)– Check

• Ongoing Premium Payments– Monthly

• Checking Account Deduction

• Credit Card

– Bi-monthly or Quarterly Billing

Tips to Speed Up Submissions• Always ask client to return application

to you

– Verify it is complete

• Fax in your complete application

– To (800) 327-9255 as listed on the application

– Using any other Fax # will cause a delay

Tips to Speed Up Submissions• Advise client to use an automatic

payment method vs. a check.

• Provide clients with the opportunity to submit online via the Agent Connect link located on your web site.

– More information is available at Agent Services at bluecrossca.com

Exclusions & Limitations

This ends our summary of medical benefits.

For more information about out-of-network coverage and what the plans do not cover, please refer to the plan-specific Evidence of Coverage booklet.

Individual Dental Products

Dental Coverage Offered• Choice of affordable dental plans

• Access to broad networks of dentists including specialists

• Three Dental Health Maintenance Organization (DHMO) Plans

• One Dental Preferred Provider Organization (PPO) Plan

Blue Cross Individual Dental HMO Features

• Must use the services of a network provider• Options by premium and plan design

– Low: Blue Cross Individual Dental Saver SelectHMO– Medium: Blue Cross Individual Dental SelectHMO– High: Blue Cross Individual Dental Premier SelectHMO

• No deductibles • Unlimited maximum benefit

Blue Cross Individual Dental HMO Plan Share of Costs

• $5 office visit for preventive care (includes two cleanings per member per year)

• Diagnostic services, no charge for oral exam and x-rays; consultations $46 per session.

• No annual maximums or waiting periods for most services

• All services (including specialty) covered for a fixed copay amount

• Orthodontia coverage included

BC Life & Health Dental PPO Features

• Choice of any dentist• Save more if you go to a network dentist • $50 annual deductible per person • Maximum three deductibles per family• Maximum $1,000 coverage per person, per

year

Individual Dental PPO Plan Share of Costs

• Preventive and diagnostic care (includes two cleanings and exams per member, per year

• Basic care (including filling) covered after three months. All services (including specialty) covered for a fixed copay amount

• Major care (including root canal) covered after 12 months

• Plan pays specified amount or amount of dentist charges, whichever is lower

Affordable Term Life Insurance for Individuals

BC Life & Health Term Life Insurance for Individuals

Anyone who qualifies for one of our Level 1 or Level 1 + 20 medical plans can purchase

– Up to $50,000 if over age 19

– Up to $30,000 (age 1-19)

BC Life & Health Term Life Insurance for Individuals

Easy to apply

– Applicant completes brief section in the Individual Enrollment Application (IU2036)

– No initial premium is required for life insurance submissions

BC Life & Health Insurance Company is rated “A” in excellence by AM Best and “A” in strength by Standard & Poor’s

Thank You for Selling Blue Cross!