Southern California Plans Available

New groups only. Effective 1/1/01.
Features	Plan 2 Member Pays	Plan 3 Member Pays	Plan 4 Member Pays	Plan 5 Member Pays

Calendar Year Deductible: Individual/ family	$0	$0	$0	$0

Out of Pocket Maximum	$1,500 individual $3,000 family	$1,500 individual $3,000 family	$1,500 individual $3,000 family	$1,500 individual $3,000 family

In the Medical Office:
-Doctor office visits	$5	$10	$15	$20
-Physical exams	$5	$10	$15	$20
-Maternity/ prenatal*	No charge	No charge	No charge	No charge
-scheduled well-child visits**	No charge	No charge	No charge	No charge
- Immunizations	No charge	No charge	No charge	No charge
- Lab, imaging, other test (mammography and pap smears included)	No charge	No charge	No charge	No charge

Emergency Services:
In or out of our Southern California Service Area (In a Plan or an Out-of-Plan Facility; waived if admitted)	$35	$35	$35	$35

Prescriptions:
Must fall within our broad Health Plan formulary guidelines (up to a 100-day supply)	$5 (per prescription)	$7 (per prescription)	$10 (per prescription)	$15 (per prescription)

Hospital and Extended Care:
Physicians' services, room and board, tests, and supplies. Skilled nursing, home health, hospice	No charge	No charge	No charge	No charge

Mental Health:
- In the Medical Office	$20 individual	$20 individual	$20 individual	$20 individual
(20 visits max./ cal. year)	$10 group	$10 group	$10 group	$10 group
- In the Hospital	No charge	No charge	No charge	No charge
(30 days max./ cal. year)

Alcohol and Drug Dependency Care:
- In the Medical Office	$5 individual	$5 individual	$5 individual	$5 individual
(counseling for dependency; medical management of withdrawal symptoms)	$2 group	$2 group	$2 group	$2 group
- In the Hospital	No charge	No charge	No charge	No charge
(medical management of the withdrawal symptoms)
- Transitional Residency Recovery (in a non-medical setting)	$100 per admission	$100 per admission	$100 per admission	$100 per admission

Durable Medical Equipment (DME) and Prosthetics	No charge	No charge	No charge	No charge

Optical (lenses & frames)	$60 per frame or $60 per set of contact lens allowed	Not covered	Not covered	Not covered