Common use of Covered Preventive Care Benefits Clause in Contracts

Covered Preventive Care Benefits. The following services shall be provided when performed by, authorized by, or deemed appropriate by the Members Primary Care Physician. The Member shall pay any copayment listed in the Member’s Benefit Agreement directly to the physician for each service performed. A. Well baby care through age 2 years, including immunizations. B. Scheduled physical examinations as set forth in the Member’s Benefit Agreement. C. Pediatric and adult immunizations. D. Eye examinations E. Infertility studies for Members aged 18 or over. F. Ear examinations. G. Health education services as follows: (1) Health education services and education in the appropriate use of health services and in the contribution each Member can make to the maintenance of his/or her own health. (2) Instruction in personal health care measures. (3) Information about services provided, including recommendations on generally accepted medical standards for use and frequency of such services. H. Services such as pre- and post-hospitalization planning; referral to services provided through community health and social welfare agencies and related family counseling for the physical, emotional and economic impact of illness and disability. I. Allergy testing and administration of injections. ACUPUNCTURE *** *** AIDS *** *** Inpatient Facility Component *** *** Professional Component *** *** ALLERGY TESTING A TREATMENT *** *** Professional Component *** *** Serums *** *** AMBULANCE: Air or Ground *** *** In-Area *** *** Out-of-Area *** *** AMNIOCENTESIS *** *** Outpatient Facility Component *** *** Professional Component *** *** ANESTHETICS, Administration of ARTIFICIAL EYE *** *** * ARTIFICIAL INSEMINATION *** *** ARTIFICIAL LIMBS (Prosthetic Device) *** *** BIOFEEDBACK *** *** BLOOD AND BLOOD PRODUCTS *** *** From Blood Bank *** *** Autologous Blood Donation *** *** * CHEMICAL DEPENDENCY REHABILITATION *** *** Inpatient Facility component *** *** Inpatient Professional Component *** *** Outpatient Facility Component *** *** Outpatient Professional Component *** *** * As set forth in the applicable Benefit Agreement. *** All references to the division of financial responsibility have been deleted. CHEMOTHERAPY DRUGS (intravenously administered) *** *** Professional Component *** *** Chemotherapy Drugs *** *** CHIROPRACTIC (Referred Service only) *** *** CIRCUMCISION *** *** COLOSTOMY SUPPLIES *** *** Inpatient Facility Component *** *** Outpatient Dispensing *** *** In Conjunction with Home Health *** *** DENTAL SERVICES (accidental injury to sound natural teeth and dental work necessary for the construction of non-dental structures) *** *** Inpatient Facility Component *** *** Professional Component *** *** DETOXIFICATION *** *** Inpatient Facility Component *** *** Professional Component *** *** * DURABLE MEDICAL EQUIPMENT (DME) *** *** EMERGENCY ADMISSIONS: In-Area *** *** Facility Component *** *** Professional Component *** *** EMERGENCY ADMISSIONS: Out-of-Area *** *** Facility Component *** *** Professional Component *** *** EMERGENCY ROOM: In-Area *** *** Facility Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement. *** All references to the division of financial responsibility have been deleted. EMERGENCY ROOM: Out-of-Area *** *** Facility Component *** *** Professional Component *** *** EMPLOYMENT PHYSICAL EXAMS *** *** ENDOSCOPIC STUDIES *** *** Inpatient / Outpatient Facility Component *** *** Professional Component *** *** EXPERIMENTAL PROCEDURES *** *** FAMILY PLANNING SERVICES *** *** Inpatient Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Professional Component *** *** FETAL MONITORING *** *** Inpatient Facility Component *** *** Professional Component *** *** GENETIC TESTING *** *** HEALTH EDUCATION *** *** ** HEALTH EVALUATIONS / PHYSICALS (required by third party or outside agency) *** *** * HEARING AIDS *** *** HEARING SCREENING *** *** HEMODIALYSIS *** *** Inpatient / Outpatient Facility Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement ** Routine physical examinations or tests which do not directly treat an actual illness, injury or condition unless authorized by a Primary Care Physician, except in no event will any physical examination or test required by employment or government authority, or at the request of a third party such as a school, camp or sport affiliated organization be covered. *** All references to the division of financial responsibility have been deleted. HEPATITIS B VACCINE / GAMMA GLOBULIN *** *** HOME HEALTH (Including medications) *** *** HOSPICE (in lieu of acute inpatient or SNF care) *** *** Inpatient Facility Component *** *** Professional Component *** *** HOSPITAL BASED PHYSICIANS *** *** Anesthesiology *** *** Audiology *** *** Cardiology *** *** Emergency Medicine *** *** General Surgery *** *** Neonatology *** *** Nephrology *** *** Neurology *** *** Neurosurgery *** *** Obstetrics / Gynecology *** *** Orthopedic Surgery *** *** Pathology *** *** Pediatrics *** *** Physical Medicine *** *** Pulmonary Medicine *** *** Radiology *** *** Radiation Oncology *** *** Urology *** *** * HOSPITALIZATION / INPATIENT SERVICES, SUPPLIES & TESTING *** *** In-Area *** *** Out-of-Area (Emergency) *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. IMMEDIATE CARE *** *** Facility Component *** *** Professional Component *** *** IMMUNIZATION SERUMS (pediatric) *** *** IMMUNIZATION SERUMS (Adult) *** *** INFANT APNEA MONITOR (DME) (in conjunction with or concurrent with authorized inpatient admission) *** *** OUTPATIENT INFANT APNEA MONITOR *** *** * INFERTILITY(Diagnosis / Treatment) *** *** *Inpatient Facility Component *** *** *Professional Component *** *** INFUSION THERAPY *** *** Inpatient / Outpatient Facility Component *** *** Professional Component *** *** Infused Substances *** *** INJECTABLE MEDICATIONS: Outpatient (excluding take-home insulin) *** *** LABORATORY SERVICES *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Professional Component *** *** * LITHOTRIPSY *** *** Inpatient / Outpatient Hospital Facility Component *** *** Professional Component *** *** MAMMOGRAPHY *** *** Technical Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. MENTAL HEALTH *** *** *Inpatient Facility Component *** *** *Inpatient Professional Component *** *** *Outpatient Professional Component *** *** NUTRITIONIST / DIETITIAN *** *** OBSTETRICAL SERVICES *** *** Inpatient Facility Component *** *** Inpatient Professional Component *** *** Outpatient Diagnostic Services *** *** OFFICE VISIT SUPPLIES, SPLINTS, CASTS, BANDAGES, DRESSINGS etc. *** *** ORGAN TRANSPLANTS (non-experimental) *** *** Inpatient Facility Component *** *** Professional Component *** *** * OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS *** *** Primary Care Physicians *** *** Specialty Physicians *** *** OUTPATIENT CLINIC OR NON-HOSPITAL FACILITY COMPONENT FOR DIAGNOSTIC SERVICES & TREATMENTS These services include, but are not limited to the following: *** *** Angiograms *** *** CAT Scan *** *** 2-D Echo *** *** EEG *** *** EKG (aka: ECG) *** *** EMG *** *** Xxxxxx Monitor *** *** MRI *** *** Treadmill *** *** Ultrasound *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS *** *** Professional Component for: *** *** Anesthesiology *** *** Audiology *** *** Cardiology *** *** Emergency Medicine *** *** General Surgery *** *** Neonatology *** *** Nephrology *** *** Neurology *** *** Obstetrics / Gynecology *** *** Orthopedics *** *** Pathology *** *** Pediatrics *** *** Physical Medicine *** *** Pulmonary Medicine *** *** Radiation Oncology *** *** Radiology *** *** Urology *** *** OUTPATIENT SURGERY *** *** Facility Component *** *** Professional Component for: *** *** Anesthesiology *** *** Audiology *** *** Cardiology *** *** Emergency Medicine *** *** Neonatology *** *** Neurology *** *** Nephrology *** *** Orthopedics *** *** Pathology *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. Pediatrics *** *** Physical Medicine *** *** Pulmonary Medicine *** *** Radiation Oncology *** *** Radiology *** *** Urology *** *** PEDIATRIC SERVICES (newborn) *** *** PHYSICAL THERAPY *** *** Inpatient Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Inpatient / Outpatient Professional Component *** *** PHYSICIAN VISITS *** *** To Hospital *** *** To Skilled Nursing Facility *** *** To Patient Home *** *** PHYSICIAN OFFICE VISITS *** *** Consultations *** *** Specialty Visits *** *** PODIATRY SERVICES *** *** PREADMISSION TESTING *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Inpatient / Outpatient Professional Component *** *** PRE-EXISTING PREGNANCY *** *** Inpatient Facility Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. PREGNANCY SERVICES *** *** Inpatient Facility Component *** *** Professional Component *** *** PROSTHETIC DEVICES *** *** RADIATION THERAPY *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic Facility Component *** *** Professional Component *** *** RADIOLOGY SERVICES *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Professional Component *** *** RECONSTRUCTIVE SURGERY *** *** Inpatient Facility Component *** *** Professional Component *** *** REFRACTIONS *** *** REHABILITATION SERVICES (Short Term: Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Therapy) *** *** Inpatient Facility Component *** *** Inpatient Professional Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Outpatient Professional Component *** *** ROUTINE PHYSICAL EXAMINATIONS *** *** SKILLED NURSING FACILITY (SNF) *** *** SPECIALIST CONSULTATIONS *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. SURGICAL SUPPLIES *** *** Inpatient Facility Component *** *** Outpatient Facility Component *** *** TEMPORO-MANDIBULAR JOINT SYNDROME (TMJ) *** *** Dental Treatment *** *** Professional Component (for the diagnosis and medically necessary correction) *** *** Inpatient Facility Component *** *** TRANSFUSIONS *** *** From Blood Bank *** *** Autologous Blood Donations *** *** URGENT CARE: In-Area *** *** Facility Component *** *** Professional Component *** *** URGENT CARE: Out-of-Area *** *** Facility Component *** *** Professional Component *** *** VISION SCREENING *** *** VISION CARE *** *** Medically Necessary Care *** *** Refraction *** *** Lenses / Frames (covered by optional rider) *** *** Contact lenses (fitting only) *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. PMPM Outpatient Prescription Drug Expense Target: $10.45 PMPM Greater than *** $0.00 *** to *** (*** PMPM OPDE) x 45% *** to *** (*** PMPM OPDE) x 50% Less than *** *** PMPM If PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less than the OPDE Target, an additional *** PMPM will be due to PARTICIPATING MEDICAL GROUP if PARTICIPATING MEDICAL GROUP’s Formulary utilization is equal to or greater than *** Formulary Utilization: Is the quotient of the number of prescriptions for Members with outpatient prescription drug benefits assigned to PARTICIPATING MEDICAL GROUP using drugs listed in the Blue Cross of California Outpatient Prescription Drug Formulary divided by the total number of prescriptions for Members with outpatient prescription drug benefits assigned to PARTICIPATING MEDICAL GROUP. Where:

Covered Preventive Care Benefits. The following services shall be provided when performed by, authorized by, or deemed appropriate by the Members Member’s Primary Care Physician. The Member shall pay any copayment listed in the Member’s Benefit Agreement directly to the physician for each service performed. A. Well baby care through age 2 years, including immunizations. B. Scheduled physical examinations as set forth in the Member’s Benefit Agreement. C. Pediatric and adult immunizations. D. Eye examinations E. Infertility studies for Members aged 18 or over. F. Ear examinations. G. F. Health education services as follows: (1) Health education services and education in the appropriate use of health services and in the contribution each Member can make to the maintenance of his/or her own health. (2) Instruction in personal health care measures. (3) Information about services provided, including recommendations on generally accepted medical standards for use and frequency of such services. H. G. Services such as pre- and post-hospitalization planning; referral to services provided through community health and social welfare agencies and related family counseling for the physical, emotional and economic impact of illness and disability. I. H. Allergy testing and administration of injections. ACUPUNCTURE *** *** *** AIDS *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** ALLERGY TESTING A & TREATMENT *** *** *** Professional Component *** *** *** Serums *** *** *** AMBULANCE: Air or Ground *** *** *** In-Area *** *** *** Out-of-Area *** *** *** AMNIOCENTESIS *** *** *** Outpatient Facility Component *** *** *** Professional Component *** *** *** ANESTHETICS, Administration of *** *** *** ARTIFICIAL EYE *** *** *** ARTIFICIAL INSEMINATION *** *** *** ARTIFICIAL LIMBS (Prosthetic Device) *** *** *** BIOFEEDBACK *** *** *** BLOOD AND BLOOD PRODUCTS *** *** *** From Blood Bank *** *** *** Autologous Blood Donation *** *** *** CHEMICAL DEPENDENCY REHABILITATION *** *** *** Inpatient Facility component Component *** *** *** Inpatient Professional Component *** *** *** Outpatient Facility Component *** *** *** Outpatient Professional Component *** *** * As set forth in the applicable Benefit Agreement. *** All references to the division of financial responsibility have been deleted. CHEMOTHERAPY DRUGS (intravenously administered) *** *** *** Professional Component *** *** *** Chemotherapy Drugs *** *** *** *** All references to division of financial responsibility have been deleted. CHIROPRACTIC (Referred Service only) *** *** *** CIRCUMCISION *** *** *** COLOSTOMY SUPPLIES *** *** *** Inpatient Facility Component *** *** *** Outpatient Dispensing *** *** *** In Conjunction with Home Health *** *** *** DENTAL SERVICES (accidental injury to sound natural teeth and dental work necessary for the construction of non-dental structures) *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** DETOXIFICATION *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** DURABLE MEDICAL EQUIPMENT (DME) *** *** *** EMERGENCY ADMISSIONS: In-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** EMERGENCY ADMISSIONS: Out-of-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** EMERGENCY ROOM: In-Area *** *** *** Facility Component *** *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement. *** All references to the division of financial responsibility have been deleted. EMERGENCY ROOM: Out-of-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** EMPLOYMENT PHYSICAL EXAMS *** *** *** *** All references to division of financial responsibility have been deleted. ENDOSCOPIC STUDIES *** *** *** Inpatient / Outpatient Facility Component *** *** *** Professional Component *** *** *** EXPERIMENTAL PROCEDURES *** *** *** FAMILY PLANNING SERVICES *** *** *** Inpatient Facility Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Professional Component *** *** *** FETAL MONITORING *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** GENETIC TESTING *** *** *** HEALTH EDUCATION *** *** *** HEALTH EVALUATIONS / PHYSICALS (1) (required by third party or outside agency) *** *** *** HEARING AIDS *** *** *** HEARING SCREENING *** *** *** HEMODIALYSIS *** *** *** Inpatient / Outpatient Facility Component *** *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement *** HEPATITIS B VACCINE / GAMMA GLOBULIN *** *** *** HOME HEALTH (including medications) *** *** *** HOSPICE (in lieu of acute inpatient or SNF care) *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** (1) Routine physical examinations or tests which do not directly treat an actual illness, injury or condition unless authorized by a Primary Care Physician, except in no event will any physical examination or test required by employment or government authority, or at the request of a third party such as a school, camp or sport affiliated organization be covered. covered *** All references to the division of financial responsibility have been deleted. HEPATITIS B VACCINE / GAMMA GLOBULIN HOSPITAL BASED PHYSICIANS *** *** HOME HEALTH (Including medications) *** *** HOSPICE (in lieu of acute inpatient or SNF care) *** *** Inpatient Facility Component *** *** Professional Component *** *** HOSPITAL BASED PHYSICIANS *** *** Anesthesiology *** *** *** Audiology *** *** *** Cardiology *** *** *** Emergency Medicine *** *** *** General Surgery *** *** *** Neonatology *** *** *** Nephrology *** *** *** Neurology *** *** *** Neurosurgery *** *** *** Obstetrics / Gynecology *** *** *** Orthopedic Surgery *** *** *** Pathology *** *** *** Pediatrics *** *** *** Physical Medicine *** *** *** Pulmonary Medicine *** *** *** Radiology *** *** *** Radiation Oncology *** *** *** Urology *** *** *** HOSPITALIZATION / INPATIENT SERVICES, SUPPLIES & TESTING *** *** *** In-Area *** *** *** Out-of-Area (Emergency) *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. IMMEDIATE CARE - In Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** IMMEDIATE CARE - Out Of Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** IMMUNIZATION SERUMS (pediatric) *** *** *** IMMUNIZATION SERUMS (Adult) *** *** *** *** All references to division of financial responsibility have been deleted. INFANT APNEA MONITOR (DME) (in conjunction with or concurrent with authorized inpatient admission) *** *** *** OUTPATIENT INFANT APNEA MONITOR *** *** *** INFERTILITY(Diagnosis / Treatment) *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** INFUSION THERAPY *** *** *** Inpatient / Outpatient Facility Component *** *** *** Professional Component *** *** *** Infused Substances *** *** *** INJECTABLE MEDICATIONS: Outpatient (excluding take-home insulin) *** *** *** LABORATORY SERVICES *** *** *** Inpatient Facility Component *** *** *** Outpatient Hospital Facility Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Professional Component *** *** *** LITHOTRIPSY *** *** *** Inpatient / Outpatient Hospital Facility Component *** *** *** Professional Component *** *** *** MAMMOGRAPHY (2) *** *** *** Technical Component *** *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. MENTAL HEALTH *** *** *** Inpatient Facility Component *** *** *** Inpatient Professional Component *** *** *** Outpatient Professional Component *** *** *** NUTRITIONIST / DIETITIAN *** *** *** (2) Limited to $75.00 per member per year *** All references to division of financial responsibility have been deleted. OBSTETRICAL SERVICES *** *** *** Inpatient Facility Component *** *** *** Inpatient Professional Component (3) *** *** *** Outpatient (non-hospital facility) Diagnostic Services (4) *** *** *** OFFICE VISIT SUPPLIES, SPLINTS, CASTS, BANDAGES, DRESSINGS etc. *** *** *** ORGAN TRANSPLANTS (non-experimental) *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS *** *** *** Primary Care Physicians *** *** *** Specialty Physicians *** *** *** OUTPATIENT CLINIC OR NON-HOSPITAL FACILITY COMPONENT FOR DIAGNOSTIC SERVICES & TREATMENTS *** *** *** These services include, but are not limited to the following: *** *** *** Angiograms *** *** *** CAT Scan *** *** *** 2-D Echo *** *** *** EEG *** *** *** EKG (aka: ECG) *** *** *** EMG *** *** *** Xxxxxx Monitor *** *** *** MRI *** *** *** Treadmill *** *** *** Ultrasound *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS *** *** *** Professional Component for: *** *** *** Anesthesiology *** *** *** Audiology *** *** *** (3) Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after delivery. (4) Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after delivery. *** All references to division of financial responsibility have been deleted. Cardiology *** *** *** Emergency Medicine *** *** *** General Surgery *** *** *** Neonatology *** *** *** Nephrology *** *** *** Neurology *** *** *** Obstetrics / Gynecology *** *** *** Orthopedics *** *** *** Pathology *** *** *** Pediatrics *** *** *** Physical Medicine *** *** *** Pulmonary Medicine *** *** *** Radiation Oncology *** *** *** Radiology *** *** *** Urology *** *** *** OUTPATIENT SURGERY *** *** *** Facility Component *** *** *** Professional Component for: *** *** *** Anesthesiology *** *** *** Audiology *** *** *** Cardiology *** *** *** Emergency Medicine *** *** *** Neonatology *** *** *** Neurology *** *** *** Nephrology *** *** *** Orthopedics *** *** *** Pathology *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. Pediatrics *** *** *** Physical Medicine *** *** *** Pulmonary Medicine *** *** *** Radiation Oncology *** *** *** Radiology *** *** *** Urology *** *** *** *** All references to division of financial responsibility have been deleted. PEDIATRIC SERVICES (newborn) *** *** *** PHYSICAL THERAPY *** *** *** Inpatient Facility Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Inpatient / Outpatient Professional Component *** *** *** PHYSICIAN VISITS *** *** *** To Hospital *** *** *** To Skilled Nursing Facility *** *** *** To Patient Home *** *** *** PHYSICIAN OFFICE VISITS *** *** *** Consultations *** *** *** Specialty Visits *** *** *** PODIATRY SERVICES *** *** *** PREADMISSION TESTING *** *** *** Inpatient Facility Component *** *** *** Outpatient Hospital Facility Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Inpatient / Outpatient Professional Component *** *** PRE-EXISTING *** PREGNANCY SERVICES *** *** *** Inpatient Facility Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. PREGNANCY SERVICES *** *** Inpatient Facility Component *** *** Professional Component (5) *** *** *** PROSTHETIC DEVICES *** *** *** RADIATION THERAPY *** *** *** Inpatient Facility Component *** *** *** Outpatient Hospital Facility Component *** *** *** Outpatient Clinic Facility Component *** *** *** Professional Component *** *** *** (5) Global Payment of $1,850.00 payable to PARTICIPATING MEDICAL GROUP after delivery. *** All references to division of financial responsibility have been deleted. RADIOLOGY SERVICES *** *** *** Inpatient Facility Component *** *** *** Outpatient Hospital Facility Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Professional Component *** *** *** RECONSTRUCTIVE SURGERY *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** REFRACTIONS *** *** *** REHABILITATION SERVICES (Short Term: Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Therapy) *** *** *** Inpatient Facility Component *** *** *** Inpatient Professional Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Outpatient Professional Component *** *** *** ROUTINE PHYSICAL EXAMINATIONS *** *** *** SKILLED NURSING FACILITY (SNF) *** *** *** SPECIALIST CONSULTATIONS *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. SURGICAL SUPPLIES *** *** *** Inpatient Facility Component *** *** *** Outpatient Facility Component *** *** *** TEMPORO-MANDIBULAR JOINT SYNDROME (TMJ) *** *** *** Dental Treatment *** *** *** Professional Component (for the diagnosis and medically necessary correction) *** *** *** Inpatient Facility Component *** *** *** TRANSFUSIONS *** *** *** From Blood Bank *** *** *** Autologous Blood Donations *** *** *** *** All references to division of financial responsibility have been deleted. URGENT CARE: In-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** URGENT CARE: Out-of-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** VISION SCREENING *** *** *** VISION CARE *** *** *** Medically Necessary Care *** *** *** Refraction *** *** *** Lenses / Frames (covered by optional rider) *** *** *** Contact lenses (fitting only) *** *** *** As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. PMPM Outpatient Prescription Drug Expense Target: $10.45 PMPM Greater than *** $0.00 *** to *** (*** PMPM OPDE) x 45% *** to *** (*** PMPM OPDE) x 50% Less than *** *** PMPM If PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less than This exhibit lists the OPDE Target, an additional *** PMPM will be due to areas in which PARTICIPATING MEDICAL GROUP if PARTICIPATING MEDICAL GROUP’s Formulary utilization is equal to or greater than *** Formulary Utilization: Is the quotient of the number of prescriptions for Members with outpatient prescription drug benefits assigned to and PARTICIPATING MEDICAL GROUP using drugs listed in the Blue Cross Physicians will have administrative responsibility. The extent and type of California Outpatient Prescription Drug Formulary divided responsibility to be undertaken will be agreed upon by the total number of prescriptions for Members with outpatient prescription drug benefits assigned to PARTICIPATING MEDICAL GROUP. Where:GROUP and BLUE CROSS through an annual audit process. A. PROFESSIONAL SERVICES ADMINISTRATION Professional Services - Schedule, control, process and report encounter information Outside Referrals - Control, process and report encounter information Ancillary - Control, process and report encounter information B. INSTITUTIONAL SERVICES ADMINISTRATION Preadmission certification process Medical Review of claims Length-of-stay (monitoring and control) C. UTILIZATION REVIEW D. PEER REVIEW, EDUCATION AND CREDENTIALING E. QUALITY MANAGEMENT

Covered Preventive Care Benefits. The following services shall be provided when performed by, authorized by, or deemed appropriate by the Members Member’s Primary Care Physician. The Member shall pay any copayment listed in the Member’s Benefit Agreement directly to the physician for each service performed. A. Well baby care through age 2 years, including immunizations. B. Scheduled physical examinations as set forth in the Member’s Benefit Agreement. C. Pediatric and adult immunizations. D. Eye examinations E. Infertility studies for Members aged 18 or over. F. Ear examinations. G. Health education services as follows: (1) Health education services and education in the appropriate use of health services and in the contribution each Member can make to the maintenance of his/or her own health. (2) Instruction in personal health care measures.. *** Confidential Treatment requested (3) Information about services provided, including recommendations on generally accepted medical standards for use and frequency of such services. H. Services such as pre- pre-and post-hospitalization planning; referral to services provided through community health and social welfare agencies and related family counseling for the physical, emotional and economic impact of illness and disability. I. Allergy testing and administration of injections. ACUPUNCTURE *** *** *** AIDS *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** ALLERGY TESTING A & TREATMENT *** *** *** Professional Component *** *** *** Serums *** *** *** AMBULANCE: Air or Ground *** *** *** In-Area *** *** *** Out-of-Area *** *** *** AMNIOCENTESIS *** *** *** Outpatient Facility Component *** *** *** Professional Component *** *** *** ANESTHETICS, Administration of *** *** *** ARTIFICIAL EYE *** *** *** * ARTIFICIAL INSEMINATION *** *** *** ARTIFICIAL LIMBS (Prosthetic Device) *** *** *** BIOFEEDBACK *** *** *** BLOOD AND BLOOD PRODUCTS *** *** *** From Blood Bank *** *** *** Autologous Blood Donation *** *** *** * CHEMICAL DEPENDENCY REHABILITATION *** *** *** Inpatient Facility component Component *** *** *** Inpatient Professional Component *** *** *** Outpatient Facility Component *** *** *** Outpatient Professional Component *** *** *** * As set forth in the applicable Benefit Agreement. Agreement *** All references to the division of financial responsibility have been deleted. CHEMOTHERAPY DRUGS (intravenously administered) *** *** *** Professional Component *** *** *** Chemotherapy Drugs *** *** *** CHIROPRACTIC (Referred Service only) *** *** *** CIRCUMCISION *** *** *** COLOSTOMY SUPPLIES *** *** *** Inpatient Facility Component *** *** *** Outpatient Dispensing *** *** *** In Conjunction with Home Health *** *** *** DENTAL SERVICES (accidental injury to sound natural teeth and dental work necessary for the construction of non-dental structures) *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** DETOXIFICATION *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** * DURABLE MEDICAL EQUIPMENT (DME) *** *** *** EMERGENCY ADMISSIONS: In-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** EMERGENCY ADMISSIONS: Out-of-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** EMERGENCY ROOM: In-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** * As set forth in the applicable Benefit Agreement. Agreement *** All references to the division of financial responsibility have been deleted. EMERGENCY ROOM: Out-of-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** EMPLOYMENT PHYSICAL EXAMS *** *** *** ENDOSCOPIC STUDIES *** *** *** Inpatient / Outpatient Facility Component *** *** *** Professional Component *** *** *** EXPERIMENTAL PROCEDURES *** *** *** FAMILY PLANNING SERVICES *** *** *** Inpatient Facility Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Professional Component *** *** *** FETAL MONITORING *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** GENETIC TESTING *** *** *** HEALTH EDUCATION *** *** *** ** HEALTH EVALUATIONS / PHYSICALS (required by third party or outside agency) *** *** *** * HEARING AIDS *** *** *** HEARING SCREENING *** *** *** HEMODIALYSIS *** *** *** Inpatient / Outpatient /Outpatient Facility Component *** *** *** Professional Component *** *** *** * As set forth in the applicable Benefit Agreement ** Routine physical examinations or tests which do not directly treat an actual illness, injury or condition unless authorized by a Primary Care Physician, except in no event will any physical examination or test required by employment or government authority, or at the request of a third party such as a school, camp or sport affiliated organization be covered. *** All references to the division of financial responsibility have been deleted. HEPATITIS B VACCINE / GAMMA GLOBULIN *** *** *** HOME HEALTH (Including including medications) *** *** *** HOSPICE (in lieu of acute inpatient or SNF care) *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** HOSPITAL BASED PHYSICIANS *** *** *** Anesthesiology *** *** *** Audiology *** *** *** Cardiology *** *** *** Emergency Medicine *** *** *** General Surgery *** *** *** Neonatology *** *** *** Nephrology *** *** *** Neurology *** *** *** Neurosurgery *** *** *** Obstetrics / Gynecology *** *** *** Orthopedic Surgery *** *** *** Pathology *** *** *** Pediatrics *** *** *** Physical Medicine *** *** *** Pulmonary Medicine *** *** *** Radiology *** *** *** Radiation Oncology *** *** *** Urology *** *** *** * HOSPITALIZATION / INPATIENT SERVICES, SUPPLIES & TESTING *** *** *** In-Area *** *** *** Out-of-Area (Emergency) *** *** *** IMMEDIATE CARE - In Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. IMMEDIATE CARE - Out Of Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** IMMUNIZATION SERUMS (pediatric) *** *** *** IMMUNIZATION SERUMS (Adult) *** *** *** INFANT APNEA MONITOR (DME) (in conjunction with or concurrent with authorized inpatient admissionadmiss) *** *** *** OUTPATIENT INFANT APNEA MONITOR *** *** *** * INFERTILITY(Diagnosis / Treatment) *** *** *** *Inpatient Facility Component *** *** *** *Professional Component *** *** *** INFUSION THERAPY *** *** *** Inpatient / Outpatient Facility Component *** *** *** Professional Component *** *** *** Infused Substances *** *** *** INJECTABLE MEDICATIONS: Outpatient (excluding take-home insulin) *** *** *** LABORATORY SERVICES *** *** *** Inpatient Facility Component *** *** *** Outpatient Hospital Facility Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Professional Component *** *** *** * LITHOTRIPSY *** *** *** Inpatient / Outpatient Hospital Facility Component *** *** *** Professional Component *** *** *** MAMMOGRAPHY *** *** Technical *** Facility Component *** *** *** Professional Component *** *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. MENTAL HEALTH SERVICES (PARITY & NON-PARITY) *** *** *** *Inpatient Facility Component Component’ *** *** *Inpatient ** *lnpatient Professional Component *** *** *** *Outpatient Professional Component *** *** NUTRITIONIST / *** NUTRITIONIST/DIETITIAN *** *** *** OBSTETRICAL SERVICES *** *** *** Inpatient Facility Component *** *** *** Inpatient Professional Component *** *** *** Outpatient Diagnostic Services *** *** *** OFFICE VISIT SUPPLIES, SPLINTS, CASTS, BANDAGES, DRESSINGS etc. *** *** *** ORGAN TRANSPLANTS (non-experimental) *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** * OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS *** *** *** Primary Care Physicians *** *** *** Specialty Physicians *** *** *** OUTPATIENT CLINIC OR NON-HOSPITAL FACILITY COMPONENT FOR DIAGNOSTIC SERVICES & TREATMENTS *** *** *** These services include, but are not limited to the following: *** *** *** Angiograms *** *** *** CAT Scan *** *** *** 2-D Echo *** *** *** EEG *** *** *** EKG (aka: ECG) ECG)c *** *** *** EMG *** *** *** Xxxxxx Monitor *** *** *** MRI *** *** *** Treadmill *** *** *** Ultrasound *** *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS *** *** *** Professional Component for: *** *** *** Anesthesiology *** *** *** Audiology *** *** *** Cardiology *** *** *** Emergency Medicine *** *** *** General Surgery *** *** *** Neonatology *** *** *** Nephrology *** *** *** Neurology *** *** *** Obstetrics / Gynecology *** *** *** Orthopedics *** *** *** Pathology *** *** *** Pediatrics *** *** *** Physical Medicine *** *** *** Pulmonary Medicine *** *** *** Radiation Oncology . *** *** *** Radiology *** *** *** Urology *** *** *** OUTPATIENT SURGERY *** *** *** Facility Component *** *** *** Professional Component for: *** *** *** Anesthesiology *** *** *** Audiology *** *** *** Cardiology *** *** *** Emergency Medicine *** *** *** Neonatology *** *** *** Neurology *** *** *** Nephrology *** *** *** Orthopedics *** *** *** Pathology *** *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. OUTPATIENT SURGERY: Professional Component *** *** *** Pediatrics *** *** *** Physical Medicine *** *** *** Pulmonary Medicine *** *** *** Radiation Oncology *** *** *** Radiology *** *** *** Urology *** *** *** PEDIATRIC SERVICES (newborn) *** *** *** PHYSICAL THERAPY *** *** *** Inpatient Facility Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Inpatient / Outpatient Professional Component *** *** *** PHYSICIAN VISITS *** *** *** To Hospital *** *** *** To Skilled Nursing Facility *** *** *** To Patient Home *** *** *** PHYSICIAN OFFICE VISITS *** *** *** Consultations *** *** *** Specialty Visits *** *** *** PODIATRY SERVICES *** *** *** PREADMISSION TESTING *** *** *** Inpatient Facility Component *** *** *** Outpatient Hospital Facility Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Inpatient / Outpatient Professional Component *** *** *** PRE-EXISTING PREGNANCY *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. PREGNANCY SERVICES *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** PROSTHETIC DEVICES *** *** *** RADIATION THERAPY *** *** *** Inpatient Facility Component *** *** *** Outpatient Hospital Facility Component *** *** *** Outpatient Clinic Facility Component *** *** *** Professional Component *** *** *** RADIOLOGY SERVICES *** *** *** Inpatient Facility Component *** *** *** Outpatient Hospital Facility Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Professional Component *** *** *** RECONSTRUCTIVE SURGERY *** *** *** Inpatient Facility Component *** *** *** Professional Component *** *** *** REFRACTIONS *** *** *** REHABILITATION SERVICES (Short Term: Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Therapy) *** *** *** Inpatient Facility Component *** *** *** Inpatient Professional Component *** *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** *** Outpatient Professional Component *** *** *** ROUTINE PHYSICAL EXAMINATIONS *** *** *** SKILLED NURSING FACILITY (SNF) *** *** *** SPECIALIST CONSULTATIONS *** *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. SURGICAL SUPPLIES *** *** *** Inpatient Facility Component *** *** *** Outpatient Facility Component *** *** *** TEMPORO-MANDIBULAR JOINT SYNDROME (TMJ) *** *** *** Dental Treatment *** *** *** Professional Component (for the diagnosis and medically necessary correction) *** *** *** Inpatient Facility Component *** *** *** TRANSFUSIONS *** *** *** From Blood Bank *** *** Autologous *** Autotogous Blood Donations *** *** *** URGENT CARE: In-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** URGENT CARE: Out-of-Area *** *** *** Facility Component *** *** *** Professional Component *** *** *** VISION SCREENING *** *** *** VISION CARE *** *** *** Medically Necessary Care *** *** *** Refraction *** *** *** Lenses / Frames (covered by optional rider) *** *** *** Contact lenses (fitting only) *** *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. PMPM Outpatient Prescription Drug Expense Target: $10.45 PMPM Greater than . (1) Century City hospital - 050579 (2) Cedars Sinai Medical Center 050625 (3) Midway hospital Medical Center 050477 (4) Xxxxxxx Medical Center 050144 *** $0.00 *** to *** (*** PMPM OPDE) x 45% *** to *** (*** PMPM OPDE) x 50% Less than *** *** PMPM If PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less than Confidential Treatment requested This exhibit lists the OPDE Target, an additional *** PMPM will be due to areas in which PARTICIPATING MEDICAL GROUP if PARTICIPATING MEDICAL GROUP’s Formulary utilization is equal to or greater than *** Formulary Utilization: Is the quotient of the number of prescriptions for Members with outpatient prescription drug benefits assigned to and PARTICIPATING MEDICAL GROUP using drugs listed in the Blue Cross Physicians will have administrative responsibility. The extent and type of California Outpatient Prescription Drug Formulary divided responsibility to be undertaken will be agreed upon by the total number of prescriptions for Members with outpatient prescription drug benefits assigned to PARTICIPATING MEDICAL GROUP. Where:GROUP and BLUE CROSS through an annual audit process. A. PROFESSIONAL SERVICES ADMINISTRATION Professional Services - Schedule, control, process and report encounter information Outside Referrals - Control, process and report encounter information Ancillary - Control, process and report encounter information B. INSTITUTIONAL SERVICES ADMINISTRATION Preadmission certification process Medical Review of claims Length-of-stay (monitoring and control) C. UTILIZATION REVIEW D. PEER REVIEW, EDUCATION AND CREDENTIALING E. QUALITY MANAGEMENT

Covered Preventive Care Benefits. The following services shall be provided when performed by, authorized by, or deemed appropriate by the Members Member’s Primary Care Physician. The Member shall pay any copayment listed in the Member’s Benefit Agreement directly to the physician for each service performed. A. Well baby care through age 2 years, including immunizations. B. Scheduled physical examinations as set forth in the Member’s Benefit Agreement. C. Pediatric and adult immunizations. D. Eye examinations E. Infertility studies for Members aged 18 or over. F. Ear examinations. G. Health education services as follows: (1) Health education services and education in the appropriate use of health services and in the contribution each Member can make to the maintenance of his/or her own health. (2) Instruction in personal health care measures. (3) Information about services provided, including recommendations on generally accepted medical standards for use and frequency of such services. H. Services such as pre- and post-hospitalization planning; referral to services provided through community health and social welfare agencies and related family counseling for the physical, emotional and economic impact of illness and disability. I. Allergy testing and administration of injections. ACUPUNCTURE *** *** AIDS *** *** Inpatient Facility Component *** *** Professional Component *** *** ALLERGY TESTING A & TREATMENT *** *** Professional Component *** *** Serums *** *** AMBULANCE: Air or Ground *** *** In-Area *** *** Out-of-Area *** *** AMNIOCENTESIS *** *** Outpatient Facility Component *** *** Professional Component *** *** ANESTHETICS, Administration of ARTIFICIAL EYE *** *** * ARTIFICIAL INSEMINATION EYE *** *** ARTIFICIAL LIMBS (Prosthetic Device) *** *** BIOFEEDBACK *** *** BLOOD AND BLOOD PRODUCTS *** *** From Blood Bank *** *** Autologous Blood Donation *** *** * CHEMICAL DEPENDENCY REHABILITATION *** *** Inpatient Facility component Component *** *** Inpatient Professional Component *** *** Outpatient Facility Component *** *** Outpatient Professional Component *** *** * As set forth in the applicable Benefit Agreement. Agreement *** All references to the division of financial responsibility responsibilities have been deleted. CHEMOTHERAPY DRUGS (intravenously administered) *** *** Professional Component *** *** Chemotherapy Drugs *** *** * CHIROPRACTIC (Referred Service only) *** *** CHOICES PLUS (Self-Referral Opt-out Benefit) *** *** CIRCUMCISION *** *** COLOSTOMY SUPPLIES *** *** Inpatient Facility Component *** *** Outpatient Dispensing *** *** In Conjunction with Home Health *** *** DENTAL SERVICES (accidental injury to sound natural teeth and dental work necessary for the construction of non-dental structures) *** *** Inpatient Facility Component *** *** Professional Component *** *** DETOXIFICATION *** *** Inpatient Facility Component *** *** Professional Component *** *** * DIABETIC SUPPLIES *** *** * DURABLE MEDICAL EQUIPMENT (DME) *** *** EMERGENCY ADMISSIONS: In-Area *** *** Facility Component *** *** Professional Component *** *** EMERGENCY ADMISSIONS: Out-of-Area *** *** Facility Component *** *** Professional Component *** *** EMERGENCY ROOM: In-Area *** *** Facility Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement. *** *All references to the division of financial responsibility responsibilities have been deleted. EMERGENCY ROOM: Out-of-Area *** *** Facility Component *** *** Professional Component *** *** EMPLOYMENT PHYSICAL EXAMS *** *** ENDOSCOPIC STUDIES *** *** Inpatient / Outpatient Facility Component *** *** Professional Component *** *** EXPERIMENTAL PROCEDURES *** *** FAMILY PLANNING SERVICES *** *** Inpatient Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Professional Component *** *** FETAL MONITORING *** *** Inpatient Facility Component *** *** Professional Component *** *** GENETIC TESTING *** *** HEALTH EDUCATION *** *** ** HEALTH EVALUATIONS / PHYSICALS (required by third party or outside agency) *** *** * HEARING AIDS *** *** HEARING SCREENING *** *** HEMODIALYSIS *** *** Inpatient / Outpatient Facility Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement ** Routine physical examinations or tests which do not directly treat an actual illness, injury or condition unless authorized by a Primary Care Physician, except in no event will any physical examination or test required by employment or government authority, or at the request of a third party such as a school, camp or sport affiliated organization be covered. *** All references to the division of financial responsibility responsibilities have been deleted. HEPATITIS B VACCINE / GAMMA GLOBULIN *** *** HOME HEALTH (Including including medications) *** *** HOSPICE (in lieu of acute inpatient or SNF care) *** *** Inpatient Facility Component *** *** Professional Component *** *** HOSPITAL BASED PHYSICIANS *** *** Anesthesiology *** *** Audiology *** *** Cardiology *** *** Emergency Medicine *** *** General Surgery *** *** Neonatology *** *** Nephrology *** *** Neurology *** *** Neurosurgery *** *** Obstetrics / Gynecology *** *** Orthopedic Surgery *** *** Pathology *** *** Pediatrics *** *** Physical Medicine *** *** Pulmonary Medicine *** *** Radiology *** *** Radiation Oncology *** *** Urology *** *** * HOSPITALIZATION / INPATIENT SERVICES, SUPPLIES & TESTING *** *** In-Area *** *** Out-of-Area (Emergency) *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. IMMEDIATE CARE / URGENT CARE CENTER *** *** In Area: *** *** Facility Component *** *** Professional Component *** *** IMMUNIZATION SERUMS (pediatric) Out of Area: *** *** Urgently Needed Services/Urgent Care *** *** IMMUNIZATION SERUMS (Adult) *** *** IMMUNOSUPRESSIVE DRUGS *** *** INFANT APNEA MONITOR (DME) (in conjunction with or concurrent with authorized inpatient admission) *** *** OUTPATIENT INFANT APNEA MONITOR *** *** * INFERTILITY(Diagnosis / Treatment) *** *** ** Inpatient Facility Component *** *** ** Professional Component *** *** INFUSION THERAPY *** *** Inpatient / Outpatient Facility Component *** *** Professional Component *** *** Infused Substances *** *** INJECTABLE MEDICATIONS: Outpatient (excluding take-home insulin) *** *** LABORATORY SERVICES *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Professional Component *** *** * LITHOTRIPSY *** *** Inpatient / Outpatient Hospital Facility Component *** *** Professional Component *** *** MAMMOGRAPHY *** *** Technical Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. MENTAL HEALTH *** *** *Inpatient Facility Component *** *** *Inpatient Professional Component *** *** *Outpatient Professional Component *** *** NUTRITIONIST / DIETITIAN DIETICIAN *** *** OBSTETRICAL SERVICES *** *** Inpatient Facility Component *** *** Inpatient Professional Component *** *** Outpatient Diagnostic Services *** *** OFFICE VISIT SUPPLIES, SPLINTS, CASTS, BANDAGES, DRESSINGS etc. *** *** ORGAN TRANSPLANTS (non-experimental) *** *** Inpatient Facility Component *** *** Professional Component *** *** * OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS *** *** Primary Care Physicians *** *** Specialty Physicians *** *** OUTPATIENT CLINIC OR NON-HOSPITAL FACILITY COMPONENT FOR DIAGNOSTIC SERVICES & TREATMENTS *** *** These services include, but are not limited to the following: *** *** Angiograms *** *** CAT Scan *** *** 2-D Echo *** *** EEG *** *** EKG (aka: ECG) *** *** EMG *** *** Xxxxxx Monitor *** *** MRI *** *** Treadmill *** *** Ultrasound *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS *** *** Professional Component for: *** *** Anesthesiology *** *** Audiology *** *** Cardiology *** *** Emergency Medicine *** *** General Surgery *** *** Neonatology *** *** Nephrology *** *** Neurology *** *** Obstetrics / Gynecology *** *** Orthopedics *** *** Pathology *** *** Pediatrics *** *** Physical Medicine *** *** Pulmonary Medicine *** *** Radiation Oncology *** *** Radiology *** *** Urology *** *** OUTPATIENT SURGERY *** *** Facility Component *** *** Professional Component for: *** *** Anesthesiology *** *** Audiology *** *** Cardiology *** *** Emergency Medicine *** *** Neonatology *** *** Neurology *** *** Nephrology *** *** Orthopedics *** *** Pathology *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. Pediatrics OUTPATIENT SURGERY; Professional Component continued *** *** Physical Medicine *** *** Pulmonary Medicine *** *** Radiation Oncology *** *** Radiology *** *** Urology Surgery *** *** PEDIATRIC SERVICES (newborn) *** *** PHYSICAL THERAPY *** *** Inpatient Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Inpatient / Outpatient Professional Component *** *** PHYSICIAN VISITS *** *** To Hospital *** *** To Skilled Nursing Facility *** *** To Patient Home *** *** PHYSICIAN OFFICE VISITS *** *** Consultations *** *** Specialty Visits *** *** PODIATRY SERVICES (Including Routine) *** *** PREADMISSION TESTING *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Inpatient / Outpatient Professional Component *** *** PRE-EXISTING PREGNANCY *** *** Inpatient Facility Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. PREGNANCY SERVICES *** *** Inpatient Facility Component *** *** Professional Component *** *** PROSTHETIC DEVICES *** *** RADIATION THERAPY *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic Facility Component *** *** Professional Component *** *** RADIOLOGY SERVICES *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Professional Component *** *** RECONSTRUCTIVE SURGERY *** *** Inpatient Facility Component *** *** Professional Component *** *** REFRACTIONS *** *** REHABILITATION SERVICES (Short Term: Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Therapy) *** *** Inpatient Facility Component *** *** Inpatient Professional Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Outpatient Professional Component *** *** ROUTINE PHYSICAL EXAMINATIONS *** *** SKILLED NURSING FACILITY (SNF) *** *** SPECIALIST CONSULTATIONS *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. SURGICAL SUPPLIES *** *** Inpatient Facility Component *** *** Outpatient Facility Component *** *** TEMPORO-MANDIBULAR JOINT SYNDROME (TMJ) *** *** Dental Treatment *** *** Professional Component (for the diagnosis and medically necessary correction) *** *** Inpatient Facility Component *** *** TRANSFUSIONS *** *** From Blood Bank *** *** Autologous Blood Donations *** *** URGENT CARECARE / IMMEDIATE CARE CENTERS *** *** In Area: In-Area *** *** Facility Component *** *** Professional Component *** *** URGENT CAREOut of Area: Out-of-Area *** *** Facility Component *** *** Professional Component Urgently Needed Services / Urgent Care *** *** VISION SCREENING *** *** VISION CARE *** *** Medically Necessary Care *** *** Refraction *** *** Lenses / Frames (covered by optional rider) *** *** Contact lenses Lenses (fitting onlyafter cataract surgery) *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. PMPM Outpatient Prescription Drug Expense Target: $10.45 PMPM Greater than *** $0.00 *** to *** (*** PMPM OPDE) x 45% *** to *** (*** PMPM OPDE) x 50% Less than *** *** PMPM If PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less than This exhibit lists the OPDE Target, an additional *** PMPM will be due to areas in which PARTICIPATING MEDICAL GROUP if PARTICIPATING MEDICAL GROUP’s Formulary utilization is equal to or greater than *** Formulary Utilization: Is the quotient of the number of prescriptions for Members with outpatient prescription drug benefits assigned to and PARTICIPATING MEDICAL GROUP using drugs listed in the Blue Cross Physician will have administrative responsibility. The extent and type of California Outpatient Prescription Drug Formulary divided responsibility to be undertaken will be agreed upon by the total number of prescriptions for Members with outpatient prescription drug benefits assigned to PARTICIPATING MEDICAL GROUP. Where:GROUP and BLUE CROSS. A. PROFESSIONAL SERVICES ADMINISTRATION Professional Services - Schedule, control, process and report encounter information Outside Referrals - Control, process and report encounter information Ancillary - Control, process and report encounter information B. INSTITUTIONAL SERVICES ADMINISTRATION Preadmission certification process Medical Review of claims Length-of-stay (monitoring and control) C. UTILIZATION REVIEW D. PEER REVIEW, EDUCATION AND CREDENTIALING E. QUALITY MANAGEMENT

Covered Preventive Care Benefits. The following services shall be provided when performed by, authorized by, or deemed appropriate by the Members Member’s Primary Care Physician. The Member shall pay any copayment listed in the Member’s Benefit Agreement directly to the physician for each service performed. A. Well baby care through age 2 years, including immunizations. B. Scheduled physical examinations as set forth in the Member’s Benefit Agreement. C. Pediatric and adult immunizations. D. Eye examinations E. Infertility studies for Members aged 18 or over.. A-1 F. Ear examinations. G. Health education services as follows: (1) Health education services and education in the appropriate use of health services and in the contribution each Member can make to the maintenance of his/or her own health. (2) Instruction in personal health care measures. (3) Information about services provided, including recommendations on generally accepted medical standards for use and frequency of such services. H. Services such as pre- and post-hospitalization planning; referral to services provided through community health and social welfare agencies and related family counseling for the physical, emotional and economic impact of illness and disability. I. Allergy testing and administration of injections. EXHIBIT A(1) BLUE CROSS SENIOR SECURE DIVISION OF FINANCIAL RESPONSIBILITIES List of Benefits/Services Capitation Non- Capitated ACUPUNCTURE *** *** AIDS *** *** Inpatient Facility Component *** *** Professional Component *** *** ALLERGY TESTING A & TREATMENT *** *** Professional Component *** *** Serums *** *** AMBULANCE: Air or Ground *** *** In-Area *** *** Out-of-Area *** *** AMNIOCENTESIS *** *** Outpatient Facility Component *** *** Professional Component *** *** ANESTHETICS, Administration of ARTIFICIAL EYE *** *** * ARTIFICIAL INSEMINATION EYE *** *** ARTIFICIAL LIMBS (Prosthetic Device) *** *** BIOFEEDBACK *** *** BLOOD AND BLOOD PRODUCTS *** *** From Blood Bank *** *** Autologous Blood Donation *** *** * CHEMICAL DEPENDENCY REHABILITATION *** *** Inpatient Facility component Component *** *** Inpatient Professional Component *** *** Outpatient Facility Component *** *** Outpatient Professional Component *** *** * As set forth in the applicable Benefit Agreement. Agreement *** All references to the division of financial responsibility responsibilities have been deleted. . A(1) 1 List of Benefits/Services Capitation Non- Capitated CHEMOTHERAPY DRUGS (intravenously administered) *** *** Professional Component *** *** Chemotherapy Drugs *** *** * CHIROPRACTIC (Referred Service only) *** *** CHOICES PLUS (Self-Referral Opt-out Benefit) *** *** CIRCUMCISION *** *** COLOSTOMY SUPPLIES *** *** Inpatient Facility Component *** *** Outpatient Dispensing *** *** In Conjunction with Home Health *** *** DENTAL SERVICES (accidental injury to sound natural teeth and dental work necessary for the construction of non-dental structures) *** *** Inpatient Facility Component *** *** Professional Component *** *** DETOXIFICATION *** *** Inpatient Facility Component *** *** Professional Component *** *** * DIABETIC SUPPLIES *** *** * DURABLE MEDICAL EQUIPMENT (DME) *** *** EMERGENCY ADMISSIONS: In-Area *** *** Facility Component *** *** Professional Component *** *** EMERGENCY ADMISSIONS: Out-of-Area *** *** Facility Component *** *** Professional Component *** *** EMERGENCY ROOM: In-Area *** *** Facility Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement. *** *All references to the division of financial responsibility responsibilities have been deleted. . A(1) 2 List of Benefits/Services Capitation Non- Capitated EMERGENCY ROOM: Out-of-Area *** *** Facility Component *** *** Professional Component *** *** EMPLOYMENT PHYSICAL EXAMS *** *** ENDOSCOPIC STUDIES *** *** Inpatient / Outpatient Facility Component *** *** Professional Component *** *** EXPERIMENTAL PROCEDURES *** *** FAMILY PLANNING SERVICES *** *** Inpatient Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Professional Component *** *** FETAL MONITORING *** *** Inpatient Facility Component *** *** Professional Component *** *** GENETIC TESTING *** *** HEALTH EDUCATION *** *** ** HEALTH EVALUATIONS / PHYSICALS (required by third party or outside agency) *** *** * HEARING AIDS *** *** HEARING SCREENING *** *** HEMODIALYSIS *** *** Inpatient / Outpatient Facility Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement ** Routine physical examinations or tests which do not directly treat an actual illness, injury or condition unless authorized by a Primary Care Physician, except in no event will any physical examination or test required by employment or government authority, or at the request of a third party such as a school, camp or sport affiliated organization be covered. *** All references to the division of financial responsibility responsibilities have been deleted. . A(1) 3 List of Benefits/Services Capitation Non- Capitated HEPATITIS B VACCINE / GAMMA GLOBULIN *** *** HOME HEALTH (Including including medications) *** *** HOSPICE (in lieu of acute inpatient or SNF care) *** *** Inpatient Facility Component *** *** Professional Component *** *** HOSPITAL BASED PHYSICIANS *** *** Anesthesiology *** *** Audiology *** *** Cardiology *** *** Emergency Medicine *** *** General Surgery *** *** Neonatology *** *** Nephrology *** *** Neurology *** *** Neurosurgery *** *** Obstetrics / Gynecology *** *** Orthopedic Surgery *** *** Pathology *** *** Pediatrics *** *** Physical Medicine *** *** Pulmonary Medicine *** *** Radiology *** *** Radiation Oncology *** *** Urology *** *** * HOSPITALIZATION / INPATIENT SERVICES, SUPPLIES & TESTING *** *** In-Area *** *** Out-of-Area (Emergency) *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. . A(1) 4 List of Benefits/Services Capitation Non- Capitated IMMEDIATE CARE / URGENT CARE CENTER *** *** In Area: *** *** Facility Component *** *** Professional Component *** *** IMMUNIZATION SERUMS (pediatric) Out of Area: *** *** Urgently Needed Services/Urgent Care *** *** IMMUNIZATION SERUMS (Adult) *** *** IMMUNOSUPRESSIVE DRUGS *** *** INFANT APNEA MONITOR (DME) (in conjunction with or concurrent with authorized inpatient admission) *** *** OUTPATIENT INFANT APNEA MONITOR *** *** * INFERTILITY(Diagnosis / Treatment) *** *** ** Inpatient Facility Component *** *** ** Professional Component *** *** INFUSION THERAPY *** *** Inpatient / Outpatient Facility Component *** *** Professional Component *** *** Infused Substances *** *** INJECTABLE MEDICATIONS: Outpatient (excluding take-home insulin) *** *** LABORATORY SERVICES *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Professional Component *** *** * LITHOTRIPSY *** *** Inpatient / Outpatient Hospital Facility Component *** *** Professional Component *** *** MAMMOGRAPHY *** *** Technical Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. . A(1) 5 List of Benefits/Services Capitation Non- Capitated MENTAL HEALTH *** *** *Inpatient Facility Component *** *** *Inpatient Professional Component *** *** *Outpatient Professional Component *** *** NUTRITIONIST / DIETITIAN DIETICIAN *** *** OBSTETRICAL SERVICES *** *** Inpatient Facility Component *** *** Inpatient Professional Component *** *** Outpatient Diagnostic Services *** *** OFFICE VISIT SUPPLIES, SPLINTS, CASTS, BANDAGES, DRESSINGS etc. *** *** ORGAN TRANSPLANTS (non-experimental) *** *** Inpatient Facility Component *** *** Professional Component *** *** * OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS *** *** Primary Care Physicians *** *** Specialty Physicians *** *** OUTPATIENT CLINIC OR NON-HOSPITAL FACILITY COMPONENT FOR DIAGNOSTIC SERVICES & TREATMENTS *** *** These services include, but are not limited to the following: *** *** Angiograms *** *** CAT Scan *** *** 2-D Echo *** *** EEG *** *** EKG (aka: ECG) *** *** EMG *** *** Xxxxxx Monitor *** *** MRI *** *** Treadmill *** *** Ultrasound *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. . A(1) 6 List of Benefits/Services Capitation Non- Capitated OUTPATIENT DIAGNOSTIC SERVICES & TREATMENTS *** *** Professional Component for: *** *** Anesthesiology *** *** Audiology *** *** Cardiology *** *** Emergency Medicine *** *** General Surgery *** *** Neonatology *** *** Nephrology *** *** Neurology *** *** Obstetrics / Gynecology *** *** Orthopedics *** *** Pathology *** *** Pediatrics *** *** Physical Medicine *** *** Pulmonary Medicine *** *** Radiation Oncology *** *** Radiology *** *** Urology *** *** OUTPATIENT SURGERY *** *** Facility Component *** *** Professional Component for: *** *** Anesthesiology *** *** Audiology *** *** Cardiology *** *** Emergency Medicine *** *** Neonatology *** *** Neurology *** *** Nephrology *** *** Orthopedics *** *** Pathology *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility responsibilities have been deleted. Pediatrics *** *** Physical Medicine *** *** Pulmonary Medicine *** *** Radiation Oncology *** *** Radiology *** *** Urology *** *** PEDIATRIC SERVICES (newborn) *** *** PHYSICAL THERAPY *** *** Inpatient Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Inpatient / Outpatient Professional Component *** *** PHYSICIAN VISITS *** *** To Hospital *** *** To Skilled Nursing Facility *** *** To Patient Home *** *** PHYSICIAN OFFICE VISITS *** *** Consultations *** *** Specialty Visits *** *** PODIATRY SERVICES *** *** PREADMISSION TESTING *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Inpatient / Outpatient Professional Component *** *** PRE-EXISTING PREGNANCY *** *** Inpatient Facility Component *** *** Professional Component *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. PREGNANCY SERVICES *** *** Inpatient Facility Component *** *** Professional Component *** *** PROSTHETIC DEVICES *** *** RADIATION THERAPY *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic Facility Component *** *** Professional Component *** *** RADIOLOGY SERVICES *** *** Inpatient Facility Component *** *** Outpatient Hospital Facility Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Professional Component *** *** RECONSTRUCTIVE SURGERY *** *** Inpatient Facility Component *** *** Professional Component *** *** REFRACTIONS *** *** REHABILITATION SERVICES (Short Term: Physical Therapy, Occupational Therapy, Speech Therapy, Cardiac Therapy) *** *** Inpatient Facility Component *** *** Inpatient Professional Component *** *** Outpatient Clinic or Non-Hospital Facility Component *** *** Outpatient Professional Component *** *** ROUTINE PHYSICAL EXAMINATIONS *** *** SKILLED NURSING FACILITY (SNF) *** *** SPECIALIST CONSULTATIONS *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. SURGICAL SUPPLIES *** *** Inpatient Facility Component *** *** Outpatient Facility Component *** *** TEMPORO-MANDIBULAR JOINT SYNDROME (TMJ) *** *** Dental Treatment *** *** Professional Component (for the diagnosis and medically necessary correction) *** *** Inpatient Facility Component *** *** TRANSFUSIONS *** *** From Blood Bank *** *** Autologous Blood Donations *** *** URGENT CARE: In-Area *** *** Facility Component *** *** Professional Component *** *** URGENT CARE: Out-of-Area *** *** Facility Component *** *** Professional Component *** *** VISION SCREENING *** *** VISION CARE *** *** Medically Necessary Care *** *** Refraction *** *** Lenses / Frames (covered by optional rider) *** *** Contact lenses (fitting only) *** *** * As set forth in the applicable Benefit Agreement *** All references to the division of financial responsibility have been deleted. PMPM Outpatient Prescription Drug Expense Target: $10.45 PMPM Greater than *** $0.00 *** to *** (*** PMPM OPDE) x 45% *** to *** (*** PMPM OPDE) x 50% Less than *** *** PMPM If PARTICIPATING MEDICAL GROUP’s PMPM OPDE is less than the OPDE Target, an additional *** PMPM will be due to PARTICIPATING MEDICAL GROUP if PARTICIPATING MEDICAL GROUP’s Formulary utilization is equal to or greater than *** Formulary Utilization: Is the quotient of the number of prescriptions for Members with outpatient prescription drug benefits assigned to PARTICIPATING MEDICAL GROUP using drugs listed in the Blue Cross of California Outpatient Prescription Drug Formulary divided by the total number of prescriptions for Members with outpatient prescription drug benefits assigned to PARTICIPATING MEDICAL GROUP. Where:.