Common use of Preventive Health Services Clause in Contracts

Preventive Health Services. If you only receive Preventive Health Services during a physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. The Blue Shield Trio HMO Health Plan Introduction to the Blue Shield Trio HMO Health Plan Trio HMO plans offer a limited selection of IPAs and medical groups from which Members must choose, and a limited network of Hospitals. The IPAs and medical groups in Trio HMO participate in account- able care organization collaborations with Blue Shield. It is important for Members to review the list of providers within the Trio HMO Physician and Hos- pital Directory before enrolling in this health plan. In many areas, there may only be one (1) IPA or Medi- cal Group from which to select a Primary Care Physician or to receive Covered Services. This Blue Shield of California (Blue Shield) Evi- dence of Coverage and Disclosure Form (EOC) de- scribes the health care coverage that is provided un- der the Group Health Service Contract between Blue Shield and the Contractholder (Employer). A Sum- xxxx of Benefits is provided with, and is incorpo- rated as part of, this EOC. Please read this EOC and Summary of Benefits care- fully. Together they explain which services are cov- ered and which are excluded. They also contain in- formation about the role of the Primary Care Physi- cian in the coordination and authorization of Cov- ered Services and Member responsibilities such as payment of Copayments, Coinsurance and De- ductibles. Capitalized terms in this EOC have a special mean- ing. Please see the Definitions section for a clear un- derstanding of these terms. Members may contact Shield Concierge with questions about their Bene- fits. Contact information can be found on the back page of this EOC. How to Use This Health Plan PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting a Primary Care Physician Each Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogist, or pediatrician as their Primary Care Physi- cian at the time of enrollment. Individual Family members must also designate a Primary Care Physician, but each may select a different provider as their Primary Care Physician. A list of Blue Shield Trio HMO Providers is available online at xxx.xxxxxxxxxxxx.xxx. Members may also call Shield Concierge at the telephone number pro- vided on the back page of this EOC for assistance in selecting a Primary Care Physician The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below on

Preventive Health Services. If you only receive Preventive Health Services during a physician Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician Physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. The Blue Shield Trio HMO Health Plan Introduction to the Blue Shield Trio HMO Health Plan Trio HMO plans offer a limited selection of IPAs and medical groups from which Members must choose, and a limited network of Hospitals. The IPAs and medical groups in Trio HMO participate in account- able care organization collaborations with Blue Shield. It is important for Members to review the list of providers within the Trio HMO Physician and Hos- pital Directory before enrolling in this health plan. In many areas, there may only be one (1) IPA or Medi- cal Group from which to select a Primary Care Physician or to receive Covered Services. This Blue Shield of California (Blue Shield) Evi- dence of Coverage and Disclosure Form (EOC) de- scribes the health care coverage that is provided un- der the Group Health Service Contract between Blue Shield and the Contractholder (Employer). A Sum- xxxx of Benefits is provided with, and is incorpo- rated as part of, this EOC. Please read this EOC and Summary of Benefits care- fully. Together they explain which services are cov- ered and which are excluded. They also contain in- formation about the role of the Primary Care Physi- cian in the coordination and authorization of Cov- ered Services and Member responsibilities such as payment of Copayments, Coinsurance and De- ductibles. Capitalized terms in this EOC have a special mean- ing. Please see the Definitions section for a clear un- derstanding of these terms. Members may contact Shield Concierge with questions about their Bene- fits. Contact information can be found on the back page of this EOC. How to Use This Health Plan PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting a Primary Care Physician Each Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogist, or pediatrician as their Primary Care Physi- cian at the time of enrollment. Individual Family members must also designate a Primary Care Physician, but each may select a different provider as their Primary Care Physician. A list of Blue Shield Trio HMO Providers is available online at xxx.xxxxxxxxxxxx.xxx. Members may also call Shield Concierge at the telephone number pro- vided on the back page of this EOC for assistance in selecting a Primary Care Physician The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below on.

Preventive Health Services. If you only receive Preventive Health Services during a physician Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician Physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. The Blue Shield Trio Access+ HMO Health Plan Introduction to the Blue Shield Trio Access+ HMO Health Plan Trio The Access+ HMO plans offer offers a limited selection wide choice of IPAs Physi- cians, Hospitals and medical groups from which Members must choose, Non-Physician Health Care Practitioners and a limited network of Hospitals. The IPAs includes special features such as Access+ Specialist and medical groups in Trio HMO participate in account- able care organization collaborations with Blue Shield. It is important for Members to review the list of providers within the Trio HMO Physician and Hos- pital Directory before enrolling in this health plan. In many areas, there may only be one (1) IPA or Medi- cal Group from which to select a Primary Care Physician or to receive Covered ServicesAccess+ Satisfaction. This Blue Shield of California (Blue Shield) Evi- dence of Coverage and Disclosure Form (EOC) de- scribes the health care coverage that is provided un- der the Group Health Service Contract between Blue Shield and the Contractholder (Employer). A Sum- xxxx of Benefits is provided with, and is incorpo- rated as part of, this EOC. Please read this EOC and Summary of Benefits care- fully. Together they explain which services are cov- ered and which are excluded. They also contain in- formation about the role of the Primary Care Physi- cian in the coordination and authorization of Cov- ered Services and Member responsibilities such as payment of Copayments, Coinsurance and De- ductibles. Capitalized terms in this EOC have a special mean- ing. Please see the Definitions section for a clear un- derstanding of these terms. Members may contact Blue Shield Concierge Customer Service with questions about their Bene- fitsBenefits. Contact information can be found on the back page of this EOC. How to Use This Health Plan PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting a Primary Care Physician Each Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogist, or pediatrician as their Primary Care Physi- cian at the time of enrollment. Individual Family members must also designate a Primary Care Physician, but each may select a different provider as their Primary Care Physician. A list of Blue Shield Trio Access+ HMO Providers is available online at xxx.xxxxxxxxxxxx.xxx. Members may also call Shield Concierge the Customer Service Department at the telephone number pro- vided provided on the back page of this EOC for assistance assis- tance in selecting a Primary Care Physician Physician. The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below onon Changing Primary Care Physicians or Designated Medical Group or IPA. The child must be enrolled with Blue Shield to continue coverage beyond the first 31 days from the date of birth or placement for adoption. See the Eligibility and Enrollment section for additional information. Primary Care Physician Relationship The Physician-patient relationship is an important element of an HMO Plan. The Member’s Primary Care Physician will make every effort to ensure that all Medically Necessary and appropriate pro- fessional services are provided in a manner com- patible with the Member’s wishes. If the Member and Primary Care Physician fail to establish a sat- isfactory relationship or disagree on a recom- mended course of treatment, the Member may con- tact Customer Service at the number provided on the back page of this EOC for assistance in select- ing a new Primary Care Physician. If a Member is not able to establish a satisfactory relationship with his or her Primary Care Physician, Blue Shield will provide access to other available Primary Care Physicians. Role of the Primary Care Physician The Primary Care Physician chosen by the Mem- practice Physician who is not her designated Pri- xxxx Care Physician without a referral from the Primary Care Physician or Medical Group/IPA. However, the obstetrician/gynecologist or family practice Physician must be in the same Medical Group/IPA as the Member’s Primary Care Physi- cian. Obstetrical and gynecological services are defined as Physician services related to:

Preventive Health Services. If you only receive Preventive Health Services during a physician Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician Physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. The Blue Shield Trio HMO Health Plan Introduction to the Blue Shield Trio HMO Health Plan Trio HMO plans offer a limited selection of IPAs and medical groups from which Members must choose, and a limited network of Hospitals. The IPAs and medical groups in Trio HMO participate in account- able care organization collaborations with Blue Shield. It is important for Members to review the list of providers within the Trio HMO Physician and Hos- pital Directory before enrolling in this health plan. In many areas, there may only be one (1) IPA or Medi- cal Group from which to select a Primary Care Physician or to receive Covered Services. This Blue Shield of California (Blue Shield) Evi- dence of Coverage and Disclosure Form (EOC) de- scribes the health care coverage that is provided un- der the Group Health Service Contract between Blue Shield and the Contractholder (Employer). A Sum- xxxx of Benefits is provided with, and is incorpo- rated as part of, this EOC. Please read this EOC and Summary of Benefits care- fully. Together they explain which services are cov- ered and which are excluded. They also contain in- formation about the role of the Primary Care Physi- cian in the coordination and authorization of Cov- ered Services and Member responsibilities such as payment of Copayments, Coinsurance and De- ductibles. Capitalized terms in this EOC have a special mean- ing. Please see the Definitions section for a clear un- derstanding of these terms. Members may contact Shield Concierge with questions about their Bene- fits. Contact information can be found on the back page of this EOC. How to Use This Health Plan PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting a Primary Care Physician Each Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogist, or pediatrician as their Primary Care Physi- cian at the time of enrollment. Individual Family members must also designate a Primary Care Physician, but each may select a different provider as their Primary Care Physician. A list of Blue Shield Trio HMO Providers is available online at xxx.xxxxxxxxxxxx.xxx. Members may also call Shield Concierge at the telephone number pro- vided on the back page of this EOC for assistance in selecting a Primary Care Physician The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below on.

Preventive Health Services. If you only receive Preventive Health Services during a physician Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician Physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. The Blue Shield Trio HMO PPO Health Plan Introduction to the Blue Shield Trio HMO of California Health Plan Trio HMO plans offer a limited selection of IPAs and medical groups from which Members must choose, and a limited network of Hospitals. The IPAs and medical groups in Trio HMO participate in account- able care organization collaborations with Blue Shield. It is important for Members to review the list of providers within the Trio HMO Physician and Hos- pital Directory before enrolling in this health plan. In many areas, there may only be one (1) IPA or Medi- cal Group from which to select a Primary Care Physician or to receive Covered Services. This Blue Shield of California (Blue Shield) Evi- dence of Coverage and Disclosure Form (EOC) de- scribes describes the health care coverage that is provided un- der under the Group Health Service Contract between Blue Shield and the Contractholder (Employer). A Sum- xxxx Summary of Benefits is provided with, and is incorpo- rated in- corporated as part of, this EOC. Please read both this EOC and Summary of Benefits care- fullyBene- fits carefully. Together they explain which services ser- vices are cov- ered covered and which are excluded. They also contain in- formation information about the role of the Primary Care Physi- cian in the coordination and authorization of Cov- ered Services and Member responsibilities responsi- bilities, such as payment of Copayments, Coinsurance Coinsur- ance and De- ductiblesDeductibles and obtaining prior autho- rization for certain services (see the Benefits Man- agement Program section). Capitalized terms in this EOC have a special mean- ing. Please see the Definitions section for a clear un- derstanding of to under- stand these terms. Members may Please contact Blue Shield Concierge with questions about their Bene- fitsBenefits. Contact information can be found on the back last page of this EOC. How to Use This Health Plan PLEASE READ THE FOLLOWING INFORMATION INFORMA- TION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting Choice of Providers This Blue Shield Health Plan is designed for Mem- bers to obtain services from Blue Shield Participat- ing Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most ser- vices. Covered Services obtained from Non-Par- ticipating Providers will usually result in a Primary higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider. Please be aware that a provider’s status as a Partic- ipating Provider or an MHSA Participating Provider may change. It is the Member’s obliga- tion to verify whether the provider chosen is a Par- ticipating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Par- ticipating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Services section for services outside of California. Blue Shield Participating Providers Blue Shield Participating Providers include pri- xxxx care Physicians, specialists, Hospitals, and Alternate Care Services Providers that have a con- tractual relationship with Blue Shield. Participat- ing Providers are listed in the Participating Provider directory. Participating Providers agree to accept Blue Shield’s payment, plus the Member’s payment of any applicable Deductibles, Copayments, Coinsur- ance or amounts in excess of specified Benefit maximums as payment-in-full for Covered Ser- vices, except as provided under the Exception for Other Coverage and the Reductions – Third Party Liability sections. This is not true of Non-Partici- pating Providers. If a Member receives services from a Non-Partici- pating Provider, Blue Shield’s payment for that service may be substantially less than the amount billed. The Subscriber is responsible for the differ- ence between the amount Blue Shield pays and the amount billed by the Non-Participating Provider. If a Member receives services at a facility that is a Participating Provider, Blue Shield’s payment for Covered Services provided by a health profes- sional at the Participating Provider facility will be paid at the Participating Provider level of Benefits, whether the health professional is a Participating Provider or Non-Participating Provider. The Mem- ber’s share of cost will not exceed the Copayment or Coinsurance due to a participating Provider un- der similar circumstances. Some services are covered only if rendered by a Participating Provider. In these instances, using a Non-Participating Provider could result in a higher share of cost to the Member or no payment by Blue Shield for the services received. Payment for Emergency Services rendered by a Physician Each or Hospital that is not a Participating Provider will be based on Blue Shield’s Allowable Amount and will be paid at the Participating level of Benefits. The Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogistis responsible for notify- ing Blue Shield within 24 hours, or pediatrician as their Primary soon as rea- sonably possible following medical stabilization of the emergency condition. Please call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. MHSA Participating Providers For Mental Health Services and Substance Use Disorder Services, Blue Shield has contracted with a Mental Health Service Administrator (MHSA). The MHSA is a specialized health care service plan licensed by the California Department of Managed Health Care, and will underwrite and de- liver Blue Shield’s Mental Health Services and Substance Use Disorder Services through a sepa- rate network of MHSA Participating Providers. MHSA Participating Providers are those providers who participate in the MHSA network and have contracted with the MHSA to provide Mental Health and Substance Use Disorder Services to Blue Shield Members. A Blue Shield Participating Provider may not be an MHSA Participating will not exceed the Copayment or Coinsurance due to an MHSA Participating Provider under similar circumstances. Continuity of Care Physi- cian Continuity of care with a Non-Participating Provider is available for the following Members: for Members who are currently seeing a provider who is no longer in the Blue Shield; or for newly- covered Members whose previous health plan was withdrawn from the market. Members who meet the eligibility requirements listed above may request continuity of care if they are being treated for acute conditions, serious chronic conditions, pregnancies (including imme- diate postpartum care), or terminal illness. Xxxxx- nuity of care may also be requested for children who are up to 36 months old, or for Members who have received authorization from a now-termi- nated provider for surgery or another procedure as part of a documented course of treatment. To request continuity of care, visit xxx.xxxxxxxxxxxx.xxx and fill out the Continuity of Care Application. Blue Shield will review the request. The Non-Participating Provider must agree to accept Blue Shield’s Allowable Amount as payment in full for ongoing care. When autho- rized, the Member may continue to see the Non- Participating Provider for up to 12 months at the time of enrollmentParticipating Provider rate. Individual Family members must also designate a Primary Care Physician, but each may select a different Provider. It is the Member’s responsibility to en- sure that the provider as their Primary Care Physicianselected for Mental Health and Substance Use Disorder Services is an MHSA Participating Provider. A list of MHSA Participating Providers are identified in the Blue Shield Trio HMO Providers is available online at xxx.xxxxxxxxxxxx.xxxBehav- ioral Health Provider Directory. Additionally, Members may also call Shield Concierge contact the MHSA directly by call- ing 0-000-000-0000. If a Member receives services at a facility that is an MHSA Participating Provider, MHSA’s pay- ment for Mental Health and Substance Use Disor- der Services provided by a health professional at the telephone MHSA Participating Provider facility will be paid at the MHSA Participating Provider level of Benefits, whether the health professional is an MHSA Participating Provider or MHSA Non-Par- ticipating Provider. The Member’s share of cost Second Medical Opinion Policy Members who have questions about their diag- noses, or believe that additional information con- cerning their condition would be helpful in deter- mining the most appropriate plan of treatment, may make an appointment with another Physician for a second medical opinion. The Member’s at- tending Physician may also offer a referral to an- other Physician for a second opinion. The second opinion visit is subject to the applica- ble Copayment, Coinsurance, Calendar Year De- ductible and all Plan Contract Benefit limitations and exclusions. State law requires that health plans disclose to Members, upon request, the timelines for respond- ing to a request for a second medical opinion. To request a copy of these timelines, you may call the Customer Service Department at the number pro- vided on the back page of this EOC for assistance in selecting a Primary Care Physician The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below onEOC.

Preventive Health Services. If you only receive Preventive Health Services during a physician Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician Physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. The Blue Shield Trio HMO Health Plan Introduction Welcome! We are happy to the Blue Shield Trio HMO Health Plan Trio HMO plans offer have you as a limited selection Member of IPAs and medical groups from which Members must choose, and a limited network of Hospitals. The IPAs and medical groups in Trio HMO participate in account- able care organization collaborations with Blue Shield. It is important for Members to review the list of providers within the Trio HMO Physician and Hos- pital Directory before enrolling in this health plan. In many areas, there may only be one (1) IPA or Medi- cal Group from which to select a Primary Care Physician or to receive Covered Services. This our Blue Shield of California (Blue Shield) Evi- dence health plan. At Blue Shield, our mission is to ensure all Californians have access to high-quality health care at an affordable price. To achieve this mission, we pledge to: • Provide personal service to you that is worthy of our family and friends; and • Build deep, trusting relationships with providers to improve the quality of health care and lower the cost. A Blue Shield health plan will help you pay for medical care and provide you with access to a network of doctors, Hospitals, and other Health Care Providers. The types of services that are covered, the providers you can see, and your share of cost when you receive care may vary depending on your plan. About this Evidence of Coverage The Combined Evidence of Coverage and Disclosure Form (EOCEvidence of Coverage) de- scribes describes the health care coverage that is provided un- der under the Group Health Service Contract (Contract) between Blue Shield and the Contractholder (your Employer). A Sum- xxxx The Evidence of Benefits is provided withCoverage tells you: • Your eligibility for coverage; • When coverage begins and ends; • How you can access care; • Which services are covered under your plan; • Which services are not covered under your plan; • When and how you must get prior authorization for certain services; and • Important financial concepts, such as Copayment, Coinsurance, Deductible, and is incorpo- rated as part Out-of, this EOC-Pocket Maximum. Please read this EOC and This Evidence of Coverage includes a Summary of Benefits care- fullysection that lists your Cost Share for Covered Services. Together they explain which services are cov- ered and which are excluded. They also contain in- formation about the role of the Primary Care Physi- cian in the coordination and authorization of Cov- ered Services and Member responsibilities such as payment of Copayments, Coinsurance and De- ductibles. Capitalized terms in Use this EOC have a special mean- ing. Please see the Definitions section for a clear un- derstanding of these terms. Members may contact Shield Concierge with questions about their Bene- fits. Contact information can be found on the back page of this EOC. How summary to Use This Health Plan PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting a Primary Care Physician Each Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogist, or pediatrician as their Primary Care Physi- cian at the time of enrollment. Individual Family members must also designate a Primary Care Physician, but each may select a different provider as their Primary Care Physician. A list of Blue Shield Trio HMO Providers is available online at xxx.xxxxxxxxxxxx.xxx. Members may also call Shield Concierge at the telephone number pro- vided on the back page of this EOC for assistance in selecting a Primary Care Physician The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member figure out what your cost will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below onyou receive care.

Preventive Health Services. If you only receive Preventive Health Services during a physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. The Blue Shield Trio HMO PPO Health Plan Introduction to the Blue Shield Trio HMO of California Health Plan Trio HMO plans offer a limited selection of IPAs and medical groups from which Members must choose, and a limited network of Hospitals. The IPAs and medical groups in Trio HMO participate in account- able care organization collaborations with Blue Shield. It is important for Members to review the list of providers within the Trio HMO Physician and Hos- pital Directory before enrolling in this health plan. In many areas, there may only be one (1) IPA or Medi- cal Group from which to select a Primary Care Physician or to receive Covered Services. This Blue Shield of California (Blue Shield) Evi- dence of Coverage and Disclosure Form (EOC) de- scribes describes the health care coverage that is provided un- der under the Group Health Service Contract between Blue Shield and the Contractholder (Employer). A Sum- xxxx Summary of Benefits is provided with, and is incorpo- rated in- corporated as part of, this EOC. Please read both this EOC and Summary of Benefits care- fullyBene- fits carefully. Together they explain which services ser- vices are cov- ered covered and which are excluded. They also contain in- formation information about the role of the Primary Care Physi- cian in the coordination and authorization of Cov- ered Services and Member responsibilities responsi- bilities, such as payment of Copayments, Coinsurance Coinsur- ance and De- ductiblesDeductibles and obtaining prior autho- rization for certain services (see the Benefits Man- agement Program section). Capitalized terms in this EOC have a special mean- ing. Please see the Definitions section for a clear un- derstanding of to under- stand these terms. Members may Please contact Blue Shield Concierge with questions about their Bene- fitsBenefits. Contact information can be found on the back last page of this EOC. How to Use This Health Plan PLEASE READ THE FOLLOWING INFORMATION INFORMA- TION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting Choice of Providers This Blue Shield Health Plan is designed for Mem- bers to obtain services from Blue Shield Participat- ing Providers and MHSA Participating Providers. However, Members may choose to seek services from Non-Participating Providers for most ser- vices. Covered Services obtained from Non-Par- ticipating Providers will usually result in a Primary higher share of cost for the Member. Some services are not covered unless rendered by a Participating Provider or MHSA Participating Provider. Please be aware that a provider’s status as a Partic- ipating Provider or an MHSA Participating Provider may change. It is the Member’s obliga- tion to verify whether the provider chosen is a Par- ticipating Provider or an MHSA Participating Provider prior to obtaining coverage. Call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. Call the MHSA to determine if a provider is an MHSA Par- ticipating Provider. See the sections below and the Summary of Benefits for more details. See the Out-of-Area Services section for services outside of California. Blue Shield Participating Providers Blue Shield Participating Providers include pri- xxxx care Physicians, specialists, Hospitals, Alter- nate Care Services Providers, and Other Providers that have a contractual relationship with Blue Shield. Participating Providers are listed in the Participating Provider directory. Participating Providers agree to accept Blue Shield’s payment, plus the Member’s payment of any applicable Deductibles, Copayments, Coinsur- ance or amounts in excess of specified Benefit maximums as payment-in-full for Covered Ser- vices, except as provided under the Exception for Other Coverage and the Reductions – Third Party Liability sections. This is not true of Non-Partici- pating Providers. If a Member receives services from a Non-Partici- pating Provider, Blue Shield’s payment for that service may be substantially less than the amount billed. The Subscriber is responsible for the differ- ence between the amount Blue Shield pays and the amount billed by the Non-Participating Provider. If a Member receives services at a facility that is a Participating Provider, Blue Shield’s payment for Covered Services provided by a health profes- sional at the Participating Provider facility will be paid at the Participating Provider level of Benefits, whether the health professional is a Participating Provider or Non-Participating Provider. The Mem- ber’s share of cost will not exceed the Copayment or Coinsurance due to a Participating Provider un- der similar circumstances. Some services are covered only if rendered by a Participating Provider. In these instances, using a Non-Participating Provider could result in a higher share of cost to the Member or no payment by Blue Shield for the services received. Payment for Emergency Services rendered by a Physician Each or Hospital that is not a Participating Provider will be based on Blue Shield’s Allowable Amount and will be paid at the Participating level of Benefits. The Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogistis responsible for notify- ing Blue Shield within 24 hours, or pediatrician as their Primary soon as rea- sonably possible following medical stabilization of the emergency condition. Please call Customer Service or visit xxx.xxxxxxxxxxxx.xxx to determine whether a provider is a Participating Provider. MHSA Participating Providers For Mental Health Services and Substance Use Disorder Services, Blue Shield has contracted with a Mental Health Service Administrator (MHSA). The MHSA is a specialized health care service plan licensed by the California Department of Managed Health Care, and will underwrite and de- liver Blue Shield’s Mental Health Services and Substance Use Disorder Services through a sepa- rate network of MHSA Participating Providers. MHSA Participating Providers are those providers who participate in the MHSA network and have contracted with the MHSA to provide Mental Health and Substance Use Disorder Services to Blue Shield Members. A Blue Shield Participating Provider may not be an MHSA Participating will not exceed the Copayment or Coinsurance due to an MHSA Participating Provider under similar circumstances. Continuity of Care Physi- cian Continuity of care with a Non-Participating Provider is available for the following Members: for Members who are currently seeing a provider who is no longer in the Blue Shield network; or for newly-covered Members whose previous health plan was withdrawn from the market. Members who meet the eligibility requirements listed above may request continuity of care if they are being treated for acute conditions, serious chronic conditions, pregnancies (including imme- diate postpartum care), or terminal illness. Xxxxx- nuity of care may also be requested for children who are up to 36 months old, or for Members who have received authorization from a now-termi- nated provider for surgery or another procedure as part of a documented course of treatment. To request continuity of care, visit xxx.xxxxxxxxxxxx.xxx and fill out the Continuity of Care Application. Blue Shield will review the request. The Non-Participating Provider must agree to accept Blue Shield’s Allowable Amount as payment in full for ongoing care. When autho- rized, the Member may continue to see the Non- Participating Provider for up to 12 months at the time of enrollmentParticipating Provider rate. Individual Family members must also designate a Primary Care Physician, but each may select a different Provider. It is the Member’s responsibility to en- sure that the provider as their Primary Care Physicianselected for Mental Health and Substance Use Disorder Services is an MHSA Participating Provider. A list of MHSA Participating Providers are identified in the Blue Shield Trio HMO Providers is available online at xxx.xxxxxxxxxxxx.xxxBehav- ioral Health Provider Directory. Additionally, Members may also call Shield Concierge contact the MHSA directly by call- ing 0-000-000-0000. If a Member receives services at a facility that is an MHSA Participating Provider, MHSA’s pay- ment for Mental Health and Substance Use Disor- der Services provided by a health professional at the telephone MHSA Participating Provider facility will be paid at the MHSA Participating Provider level of Benefits, whether the health professional is an MHSA Participating Provider or MHSA Non-Par- ticipating Provider. The Member’s share of cost Second Medical Opinion Policy Members who have questions about their diag- noses, or believe that additional information con- cerning their condition would be helpful in deter- mining the most appropriate plan of treatment, may make an appointment with another Physician for a second medical opinion. The Member’s at- tending Physician may also offer a referral to an- other Physician for a second opinion. The second opinion visit is subject to the applica- ble Copayment, Coinsurance, Calendar Year De- ductible and all Plan Contract Benefit limitations and exclusions. State law requires that health plans disclose to Members, upon request, the timelines for respond- ing to a request for a second medical opinion. To request a copy of these timelines, you may call the Customer Service Department at the number pro- vided on the back page of this EOC for assistance in selecting a Primary Care Physician The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below onEOC.

Preventive Health Services. If you only receive Preventive Health Services during a physician Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician Physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. The Blue Shield Trio HMO Health Plan Introduction to the Blue Shield Trio HMO Health Plan Trio HMO plans offer a limited selection of IPAs and medical groups from which Members must choose, and a limited network of Hospitals. The IPAs and medical groups in Trio HMO participate in account- able care organization collaborations with Blue Shield. It is important for Members to review the list of providers within the Trio HMO Physician and Hos- pital Directory before enrolling in this health plan. In many areas, there may only be one (1) IPA or Medi- cal Group from which to select a Primary Care Physician or to receive Covered Services. This Blue Shield of California (Blue Shield) Evi- dence of Coverage and Disclosure Form (EOC) de- scribes the health care coverage that is provided un- der the Group Health Service Contract between Blue Shield and the Contractholder (Employer). A Sum- xxxx of Benefits is provided with, and is incorpo- rated as part of, this EOC. Please read this EOC and Summary of Benefits care- fully. Together they explain which services are cov- ered and which are excluded. They also contain in- formation about the role of the Primary Care Physi- cian in the coordination and authorization of Cov- ered Services and Member responsibilities such as payment of Copayments, Coinsurance and De- ductibles. Capitalized terms in this EOC have a special mean- ing. Please see the Definitions section for a clear un- derstanding of these terms. Members may contact Shield Concierge with questions about their Bene- fits. Contact information can be found on the back page of this EOC. How to Use This Health Plan PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting a Primary Care Physician Each Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogist, or pediatrician as their Primary Care Physi- cian at the time of enrollment. Individual Family members must also designate a Primary Care Physician, but each may select a different provider as their Primary Care Physician. A list of Blue Shield Trio HMO Providers is available online at xxx.xxxxxxxxxxxx.xxx. Members may also call Shield Concierge at the telephone number pro- vided on the back page of this EOC for assistance in selecting a Primary Care Physician The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below on

Preventive Health Services. If you only receive Preventive Health Services during a physician Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician Physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. The Blue Shield Trio Access+ HMO Health Plan Introduction to the Blue Shield Trio Access+ HMO Health Plan Trio The Access+ HMO plans offer offers a limited selection wide choice of IPAs Physi- cians, Hospitals and medical groups from which Members must choose, Non-Physician Health Care Practitioners and a limited network of Hospitals. The IPAs includes special features such as Access+ Specialist and medical groups in Trio HMO participate in account- able care organization collaborations with Blue Shield. It is important for Members to review the list of providers within the Trio HMO Physician and Hos- pital Directory before enrolling in this health plan. In many areas, there may only be one (1) IPA or Medi- cal Group from which to select a Primary Care Physician or to receive Covered ServicesAccess+ Satisfaction. This Blue Shield of California (Blue Shield) Evi- dence of Coverage and Disclosure Form (EOC) de- scribes the health care coverage that is provided un- der the Group Health Service Contract between Blue Shield and the Contractholder (Employer). A Sum- xxxx of Benefits is provided with, and is incorpo- rated as part of, this EOC. Please read this EOC and Summary of Benefits care- fully. Together they explain which services are cov- ered and which are excluded. They also contain in- formation about the role of the Primary Care Physi- cian in the coordination and authorization of Cov- ered Services and Member responsibilities such as payment of Copayments, Coinsurance and De- ductibles. Capitalized terms in this EOC have a special mean- ing. Please see the Definitions section for a clear un- derstanding of these terms. Members may contact Blue Shield Concierge Customer Service with questions about their Bene- fitsBenefits. Contact information can be found on the back page of this EOC. How to Use This Health Plan PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting a Primary Care Physician Each Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogist, or pediatrician as their Primary Care Physi- cian at the time of enrollment. Individual Family members must also designate a Primary Care Physician, but each may select a different provider as their Primary Care Physician. A list of Blue Shield Trio Access+ HMO Providers is available online at xxx.xxxxxxxxxxxx.xxx. Members may also call Shield Concierge the Customer Service Department at the telephone number pro- vided provided on the back page of this EOC for assistance assis- tance in selecting a Primary Care Physician Physician. The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below onon Changing Primary Care Physicians or Designated Medical Group or IPA. The child must be enrolled with Blue Shield to continue coverage beyond the first 31 days from the date of birth or placement for adoption. See the Eligibility and Enrollment section for additional information. Primary Care Physician Relationship The Physician-patient relationship is an important element of an HMO Plan. The Member’s Primary Care Physician will make every effort to ensure that all Medically Necessary and appropriate pro- fessional services are provided in a manner com- patible with the Member’s wishes. If the Member and Primary Care Physician fail to establish a sat- isfactory relationship or disagree on a recom- mended course of treatment, the Member may con- tact Customer Service at the number provided on the back page of this EOC for assistance in select- ing a new Primary Care Physician. If a Member is not able to establish a satisfactory relationship with his or her Primary Care Physician, Blue Shield will provide access to other available Primary Care Physicians. Role of the Primary Care Physician The Primary Care Physician chosen by the Mem- practice Physician who is not her designated Pri- xxxx Care Physician without a referral from the Primary Care Physician or Medical Group/IPA. However, the obstetrician/gynecologist or family practice Physician must be in the same Medical Group/IPA as the Member’s Primary Care Physi- cian. Obstetrical and gynecological services are defined as Physician services related to:

Preventive Health Services. If you only receive Preventive Health Services during a physician Physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician Physician office visit, you may have a Copayment or Coinsurance for the visit. Benefit Plans may be modified to ensure compliance with State and Federal requirements. The Blue Shield Trio HMO Health Plan Introduction to the Blue Shield Trio HMO Health Plan Trio HMO plans offer a limited selection of IPAs and medical groups from which Members must choose, and a limited network of Hospitals. The IPAs and medical groups in Trio HMO participate in account- able care organization collaborations with Blue Shield. It is important for Members to review the list of providers within the Trio HMO Physician and Hos- pital Directory before enrolling in this health plan. In many areas, there may only be one (1) IPA or Medi- cal Group from which to select a Primary Care Physician or to receive Covered Services. This Blue Shield of California (Blue Shield) Evi- dence of Coverage and Disclosure Form (EOC) de- scribes the health care coverage that is provided un- der the Group Health Service Contract between Blue Shield and the Contractholder (Employer). A Sum- xxxx of Benefits is provided with, and is incorpo- rated as part of, this EOC. Please read this EOC and Summary of Benefits care- fully. Together they explain which services are cov- ered and which are excluded. They also contain in- formation about the role of the Primary Care Physi- cian in the coordination and authorization of Cov- ered Services and Member responsibilities such as payment of Copayments, Coinsurance and De- ductibles. Capitalized terms in this EOC have a special mean- ing. Please see the Definitions section for a clear un- derstanding of these terms. Members may contact Shield Concierge with questions about their Bene- fits. Contact information can be found on the back page of this EOC. How to Use This Health Plan PLEASE READ THE FOLLOWING INFORMATION SO YOU WILL KNOW FROM WHOM OR WHAT GROUP OF PROVIDERS HEALTH CARE MAY BE OBTAINED. Selecting a Primary Care Physician Each Member must select a general practitioner, family practitioner, internist, obstetrician/gynecol- ogist, or pediatrician as their Primary Care Physi- cian at the time of enrollment. Individual Family members must also designate a Primary Care Physician, but each may select a different provider as their Primary Care Physician. A list of Blue Shield Trio HMO Providers is available online at xxx.xxxxxxxxxxxx.xxx. Members may also call Shield Concierge at the telephone number pro- vided on the back page of this EOC for assistance in selecting a Primary Care Physician The Member’s Primary Care Physician must be lo- cated sufficiently close to the Member’s home or work address to ensure reasonable access to care, as determined by Blue Shield. If the Member does not select a Primary Care Physician at the time of enrollment, Blue Shield will designate a Primary Care Physician and the Member will be notified. This designation will remain in effect until the Member requests a change. A Primary Care Physician must also be selected for a newborn or child placed for adoption within 31 days from the date of birth or placement for adoption. The selection may be made prior to the birth or placement for adoption and a pediatrician may be selected as the Primary Care Physician. For the month of birth, the Primary Care Physician must be in the same Medical Group or Independent Practice Association (IPA) as the mother’s Pri- xxxx Care Physician when the newborn is the nat- ural child of the mother. If the mother of the new- born is not enrolled as a Member or if the child has been placed with the Subscriber for adoption, the Primary Care Physician selected must be a Physi- cian in the same Medical Group or IPA as the Sub- xxxxxxx. If a Primary Care Physician is not selected for the child, Blue Shield will designate a Primary Care Physician from the same Medical Group or IPA as the natural mother or the Subscriber. This designation will remain in effect for the first cal- endar month during which the birth or placement for adoption occurred. To change the Primary Care Physician for the child after the first month, see the section below on