Common use of TABLE OF CONTENTS PAGE Clause in Contracts

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 16 How to Use This Health Plan 16 Selecting a Primary Care Physician 16 Primary Care Physician Relationship 17 Role of the Primary Care Physician 17 Obstetrical/Gynecological (OB/GYN) Physician Services 17 Referral to Specialty Services 17 Role of the Medical Group or IPA 18 Changing Primary Care Physicians or Designated Medical Group or IPA 18 Trio+ Specialist 19 Trio+ Satisfaction 19 Mental Health and Substance Use Disorder Services 19 Continuity of Care 20 Second Medical Opinion 21 Urgent Services 21 Emergency Services 22 Claims for Emergency and Urgent Services 22 NurseHelp 24/7 sm 22 Life Referrals 24/7 23 Blue Shield Online 23 Health Education and Health Promotion Services 23 Timely Access to Care 23 Cost Sharing 23 Limitation of Liability 25 Out-of-Area Services 25 Inter-Plan Arrangements 25 BlueCard Program 25 Blue Shield Global Core 26 Utilization Management 27 Principal Benefits and Coverages (Covered Services) 27 Allergy Testing and Treatment Benefits 27 Ambulance Benefits 28 Ambulatory Surgery Center Benefits 28 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 28 Diabetes Care Benefits 29 Durable Medical Equipment Benefits 29 Emergency Room Benefits 30 Family Planning and Infertility Benefits 30 Home Health Care Benefits 31 Home Infusion and Home Injectable Therapy Benefits 31 Hospice Program Benefits 32 Hospital Benefits (Facility Services) 33 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 34 Mental Health and Substance Use Disorder Benefits 35 Orthotics Benefits 36 Outpatient X-Ray, Pathology and Laboratory 36 PKU Related Formulas and Special Food Products Benefits 36 Podiatric Benefits 37 Pregnancy and Maternity Care Benefits 37 Preventive Health Benefits 37 Professional (Physician) Benefits 38 Prosthetic Appliances Benefits 39 Reconstructive Surgery Benefits 39 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 39 Skilled Nursing Facility Benefits 40 Speech Therapy Benefits (Rehabilitation and Habilitative Services) 40 Transplant Benefits 40 Urgent Services Benefits 41 Principal Limitations, Exceptions, Exclusions and Reductions 41 General Exclusions and Limitations 41 Medical Necessity Exclusion 44 Limitations for Duplicate Coverage 44 Exception for Other Coverage 45 Table of Contents Page Claims Review 45 Reductions - Third Party Liability 45 Coordination of Benefits 46 Conditions of Coverage 47 Eligibility and Enrollment 47 Effective Date of Coverage 48 Premiums (Dues) 48 Grace Period 48 Plan Changes 48 Renewal of Group Health Service Contract 49 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 49 Extension of Benefits 51 Group Continuation Coverage 51 General Provisions 54 Plan Service Area 54 Liability of Subscribers in the Event of Non-Payment by Blue Shield 54 Right of Recovery 54 No Lifetime Benefit Maximum 55 No Annual Dollar Limits on Essential Health Benefits 55 Payment of Providers 55 Facilities 55 Independent Contractors 55 Non-Assignability 56 Plan Interpretation 56 Public Policy Participation Procedure 56 Confidentiality of Personal and Health Information 56 Access to Information 57 Grievance Process 57 Medical Services 57 Mental Health and Substance Use Disorder Services 58 External Independent Medical Review 58 Department of Managed Health Care Review 59 Shield Concierge 59 Definitions 59 Notice of the Availability of Language Assistance Services 72 Outpatient Prescription Drug Benefits 73 Chiropractic Services 79 Contacting Blue Shield of California 82 Trio HMO Service Area Chart 83 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 98 Summary of Benefits Custom Trio HMO Zero Admit 10 City of Delano Effective July 1, 2018 HMO Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Benefit plan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage (EOC).1 Please read both documents carefully for details. Provider Network: Trio ACO HMO Network This benefit plan uses a specific network of health care providers, called the Trio ACO HMO provider network. Medical groups, independent practice associations (IPAs), and physicians in this network are called participating providers. You must select a primary care physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this plan. You can find participating providers in this network at xxxxxxxxxxxx.xxx. Calendar Year Deductibles (CYD)2 Blue Shield of California is an independent member of the Blue Shield Association A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Benefit plan. When using a participating provider3 Calendar year medical deductible Individual coverage $0 Calendar Year Out-of-Pocket Maximum4 Family coverage $0: individual $0: family An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the EOC. When using a participating provider3 Individual coverage $1,000 Family coverage $1,000: individual $2,000: family No Lifetime Benefit Maximum Under this Benefit plan there is no dollar limit on the total amount Blue Shield will pay for Covered Services in a Member’s lifetime. A47045 (07/18) 9 Benefits5 Your payment When using a participating provider3 CYD2 applies Preventive Health Services6 $0 Physician services Primary care office visit Trio+ specialist care office visit Other specialist care office visit Physician home visit Physician or surgeon services in an outpatient facility Physician or surgeon services in an inpatient facility $10/visit $20/visit $10/visit $25/visit $0 $0 Other professional services Other practitioner office visit Includes nurses, nurse practitioners, and therapists. Teladoc consultation Family planning  Counseling, consulting, and education  Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure.  Tubal ligation  Vasectomy  Infertility services Podiatric services $10/visit $5/consult $0 $0 $0 $0 50% $10/visit Pregnancy and maternity care6 Physician office visits: prenatal and postnatal $0 Physician services for pregnancy termination $0 Emergency services and urgent care Emergency room services If admitted to the hospital, this payment for emergency room services does not apply. Instead, you pay the participating provider payment under Inpatient facility services/ Hospital services and stay. Emergency room physician services $100/visit $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Urgent care physician services $10/visit Inside your primary care physician’s service area, services must be provided or referred by your primary care physician or medical group/IPA. Services outside your primary care physician’s service area are also covered. Services inside your primary care physician’s service area not provided or referred by your primary care physician or medical group/IPA are not covered. Ambulance services $100/transport Outpatient facility services Ambulatory surgery center $0 Outpatient department of a hospital: surgery $0 Outpatient department of a hospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies Inpatient facility services Hospital services and stay $0 Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.  Special transplant facility inpatient services $0  Physician inpatient services $0 Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services that are diagnostic, non- preventive health services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test.  Laboratory center $0  Outpatient department of a hospital $0  California Prenatal Screening Program $0 X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center $0  Outpatient department of a hospital $0 Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG.  Office location $0  Outpatient department of a hospital $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Radiological and nuclear imaging services  Outpatient radiology center $0  Outpatient department of a hospital $0 Rehabilitation and habilitative services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location $10/visit Outpatient department of a hospital $10/visit Durable medical equipment (DME) DME $0 Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices $0 Home health services Up to 100 visits per member, per calendar year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible period, except hemophilia and home infusion nursing visits. Home health agency services $10/visit Includes home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. Home visits by an infusion nurse $10/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. Skilled nursing facility (SNF) services Up to 100 days per member, per benefit period, except when provided as part of a hospice program. All days count towards the limit, including days during any applicable deductible period and days in different SNFs during the calendar year. Freestanding SNF $0 Hospital-based SNF $0 Hospice program services $0 Includes pre-hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Benefits5 Your payment When using a participating provider3 CYD2 applies Other services and supplies Diabetes care services  Devices, equipment, and supplies $0  Self-management training $10/visit Dialysis services $0 PKU product formulas and special food products $0 Allergy serum 50% Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder benefits are provided through Blue Shield's mental health services administrator (MHSA). When using a MHSA participating provider3 CYD2 applies Outpatient services Office visit, including physician office visit $10/visit Other outpatient services, including intensive outpatient care, behavioral health treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility $0 setting, and office-based opioid treatment Partial hospitalization program $0 Psychological testing $0 Inpatient services Physician inpatient services $0 Hospital services $0 Residential care $0 Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the benefits, limitations, and exclusions that apply to coverage under this benefit plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 16 15 How to Use This Health Plan 16 15 Selecting a Primary Care Physician 16 15 Primary Care Physician Relationship 17 16 Role of the Primary Care Physician 17 16 Obstetrical/Gynecological (OB/GYN) Physician Services 17 16 Referral to Specialty Services 17 16 Role of the Medical Group or IPA 18 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Specialist 19 Trio+ Satisfaction 19 18 Mental Health and Substance Use Disorder Services 19 18 Continuity of Care 20 19 Second Medical Opinion 21 20 Urgent Services 21 20 Emergency Services 22 21 Claims for Emergency and Urgent Services 22 21 NurseHelp 24/7 sm 22 21 Life Referrals 24/7 23 22 Blue Shield Online 23 22 Health Education and Health Promotion Services 23 22 Timely Access to Care 23 22 Cost Sharing 23 22 Limitation of Liability 25 24 Out-of-Area Services 25 24 Inter-Plan Arrangements 25 24 BlueCard Program 25 24 Blue Shield Global Core 26 25 Utilization Management 27 26 Principal Benefits and Coverages (Covered Services) 27 26 Allergy Testing and Treatment Benefits 27 26 Ambulance Benefits 28 26 Ambulatory Surgery Center Benefits 28 27 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 28 27 Diabetes Care Benefits 29 28 Durable Medical Equipment Benefits 29 28 Emergency Room Benefits 30 29 Family Planning and Infertility Benefits 30 29 Home Health Care Benefits 31 30 Home Infusion and Home Injectable Therapy Benefits 31 30 Hospice Program Benefits 32 31 Hospital Benefits (Facility Services) 33 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 34 33 Mental Health and Substance Use Disorder Benefits 35 34 Orthotics Benefits 36 35 Outpatient X-Ray, Pathology and Laboratory 36 35 PKU Related Formulas and Special Food Products Benefits 36 35 Podiatric Benefits 37 35 Pregnancy and Maternity Care Benefits 37 36 Preventive Health Benefits 37 36 Professional (Physician) Benefits 38 36 Prosthetic Appliances Benefits 39 38 Reconstructive Surgery Benefits 39 Rehabilitation 38 Rehabilitative and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 39 38 Skilled Nursing Facility Benefits 40 38 Speech Therapy Benefits (Rehabilitation Rehabilitative and Habilitative Services) 40 39 Transplant Benefits 40 39 Urgent Services Benefits 41 39 Principal Limitations, Exceptions, Exclusions and Reductions 41 40 General Exclusions and Limitations 41 40 Medical Necessity Exclusion 44 43 Table of Contents Page Limitations for Duplicate Coverage 44 43 Exception for Other Coverage 45 Table of Contents Page 44 Claims Review 45 44 Reductions - Third Party Liability 45 44 Coordination of Benefits 46 45 Conditions of Coverage 47 46 Eligibility and Enrollment 47 46 Effective Date of Coverage 48 47 Premiums (Dues) 48 47 Grace Period 48 47 Plan Changes 48 47 Renewal of Group Health Service Contract 49 47 Termination of Benefits (Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 49 Coverage) 48 Extension of Benefits 51 50 Group Continuation Coverage 51 50 General Provisions 54 53 Plan Service Area 54 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 54 53 Right of Recovery 54 53 No Lifetime Benefit Maximum 55 54 No Annual Dollar Limits on Essential Health Benefits 55 54 Payment of Providers 55 54 Facilities 55 54 Independent Contractors 55 54 Non-Assignability 56 54 Plan Interpretation 56 55 Public Policy Participation Procedure 56 55 Confidentiality of Personal and Health Information 56 55 Access to Information 57 55 Grievance Process 57 56 Medical Services 57 56 Mental Health and Substance Use Disorder Services 58 56 External Independent Medical Review 58 57 Department of Managed Health Care Review 59 58 Shield Concierge 59 58 Definitions 59 58 Notice of the Availability of Language Assistance Services 72 70 Acupuncture and Chiropractic Services Rider 71 Outpatient Prescription Drug Benefits 73 Chiropractic Services 79 Rider 74 Contacting Blue Shield of California 82 83 Trio HMO Service Area Chart 83 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 98 84 Summary of Benefits Custom Trio HMO Zero Admit 10 City of Delano Effective July 1, 2018 Facility Deductible 30-30%/2000 Group Plan HMO Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Benefit planPlan. It is only a summary and it is included as part of the contract for health care coverage, called the Evidence of Coverage (EOC).1 Please read both documents carefully for details. Medical Provider Network: Trio ACO HMO Network This benefit plan Plan uses a specific network of health care providersHealth Care Providers, called the Trio ACO HMO provider network. Medical groupsGroups, independent practice associations Independent Practice Associations (IPAs), and physicians Physicians in this network are called participating providersParticipating Providers. You must select a primary care physician Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this planPlan. You can find participating providers Participating Providers in this network at xxxxxxxxxxxx.xxx. Calendar Year Deductibles (CYD)2 Blue Shield of California is an independent member of the Blue Shield Association A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Benefit planPlan. Blue Shield pays for some Covered Services before the Calendar Year Deductible is met, as noted in the Benefits chart below. Blue Shield of California is an independent member of the Blue Shield Association When using a participating provider3 Participating Provider3 Calendar year Year medical deductible Deductible Individual coverage $0 2,000 Family coverage $2,000: individual $4,000: Family Calendar Year Out-of-Pocket Maximum4 Family coverage $0: individual $0: family An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the EOC. When using a participating provider3 Participating Provider3 Individual coverage $1,000 3,500 Family coverage $1,0003,500: individual $2,0007,000: family Family No Annual or Lifetime Benefit Maximum Dollar Limit Under this Benefit plan Plan there is no annual or lifetime dollar limit on the total amount Blue Shield will pay for Covered Services in a Member’s lifetimeServices. A47045 A47059 (07/1801/20) 9 Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Preventive Health Services6 Preventive Health Services California Prenatal Screening Program $0 $0 Physician services Primary care office visit Trio+ specialist care office visit (self-referral) Other specialist care office visit (referred by PCP) Physician home visit Physician or surgeon services in an outpatient facility Physician or surgeon services in an inpatient facility $1030/visit $2030/visit $1030/visit $2530/visit $0 $0 Other professional services Other practitioner office visit Includes nurses, nurse practitioners, physician assistants, and therapists. Teladoc consultation Family planning  • Counseling, consulting, and education  • Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure.  • Tubal ligation  • Vasectomy  Infertility services Podiatric services $1030/visit $5/consult $0 $0 $0 $0 50% $100 $30/visit Pregnancy and maternity care6 Physician office visits: prenatal and postnatal $0 Physician services for pregnancy termination $0 $0 Emergency services and urgent care Emergency room services If admitted to the hospitalHospital, this payment for emergency room services does not apply. Instead, you pay the participating provider Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room physician Physician services $100150/visit $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Urgent care physician center services $1030/visit Inside your primary care physician’s service area, services must be provided or referred by your primary care physician or medical group/IPA. Services outside your primary care physician’s service area are also covered. Services inside your primary care physician’s service area not provided or referred by your primary care physician or medical group/IPA are not covered. Ambulance services This payment is for emergency or authorized transport. $100/transport Outpatient facility services Ambulatory surgery center $0 Surgery Center 20% ✔ Benefits5 Your payment When using a Participating Provider3 CYD2 applies Outpatient department Department of a hospitalHospital: surgery $0 Outpatient department Department of a hospitalHospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies 30% $0 ✔ Inpatient facility services Hospital services and stay $0 Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.  • Special transplant facility inpatient services $0  • Physician inpatient services 30% 30% $0 ✔ ✔ Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services Covered Services that are diagnostic, non- preventive health servicesPreventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test.  • Laboratory center $0  • Outpatient department Department of a hospital $0  California Prenatal Screening Program $0 Hospital X-ray and imaging services Includes diagnostic mammography.  • Outpatient radiology center $0  • Outpatient department Department of a hospital $0 Hospital Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG.  • Office location • Outpatient Department of a Hospital Radiological and nuclear imaging services • Outpatient radiology center • Outpatient Department of a Hospital $0  $0 $0 $0 $0 $0 $0 $0 Rehabilitative and Habilitative Services Includes Physical Therapy, Occupational Therapy, Respiratory Therapy, and Speech Therapy services. Office location Outpatient department Department of a hospital Hospital $0 30/visit $30/visit Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Radiological and nuclear imaging services  Outpatient radiology center $0  Outpatient department of a hospital $0 Rehabilitation and habilitative services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location $10/visit Outpatient department of a hospital $10/visit Durable medical equipment (DME) DME $0 Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices 50% $0 $0 $0 Home health care services Up to 100 visits per memberMember, per calendar yearCalendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible Deductible period, except hemophilia and home infusion nursing visits. Home health agency services $10/visit Includes home visits by a nurse, home health aideHome Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. $30/visit Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse $10/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. $0 $30/visit $0 Skilled nursing facility Nursing Facility (SNF) services Up to 100 days per memberMember, per benefit periodBenefit Period, except when provided as part of a hospice Hospice program. All days count towards the limit, including days during any applicable deductible Deductible period and days in different SNFs during the calendar yearCalendar Year. Freestanding SNF $0 Hospital-based SNF $0 30% 30% ✔✔ Hospice program services $0 Includes pre-hospice Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Benefits5 Your payment When using a participating provider3 CYD2 applies $0 Other services and supplies Diabetes care services  • Devices, equipment, and supplies $0  • Self-management training $10/visit Dialysis services $0 PKU product formulas and special food products Special Food Products Allergy serum billed separately from an office visit 20% $30/visit $0 Allergy serum $0 50% Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder benefits Benefits are provided through Blue Shield's mental health services administrator Mental Health Service Administrator (MHSA). When using a MHSA participating provider3 Participating Provider3 CYD2 applies Outpatient services Office visit, including physician Physician office visit $1030/visit Other outpatient services, including intensive outpatient care, behavioral health treatment electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility $0 setting, and office-based opioid treatment $0 Partial hospitalization program Hospitalization Program $0 Psychological testing Testing $0 Inpatient services Physician inpatient services $0 Hospital services $0 30% ✔ Residential care $0 Care 30% ✔ Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the benefitsBenefits, limitations, and exclusions that apply to coverage under this benefit planPlan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 16 15 How to Use This Health Plan 16 15 Selecting a Primary Care Physician 16 15 Primary Care Physician Relationship 17 16 Role of the Primary Care Physician 17 16 Obstetrical/Gynecological (OB/GYN) Physician Services 17 16 Referral to Specialty Services 17 16 Role of the Medical Group or IPA 18 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Specialist 19 Trio+ Satisfaction 19 18 Mental Health and Substance Use Disorder Services 19 18 Continuity of Care 20 19 Second Medical Opinion 21 20 Urgent Services 21 20 Emergency Services 22 21 Claims for Emergency and Urgent Services 22 21 NurseHelp 24/7 sm 22 21 Life Referrals 24/7 23 22 Blue Shield Online 23 22 Health Education and Health Promotion Services 23 22 Timely Access to Care 23 22 Cost Sharing 23 22 Limitation of Liability 25 24 Out-of-Area Services 25 24 Inter-Plan Arrangements 25 24 BlueCard Program 25 24 Blue Shield Global Core 26 25 Utilization Management 27 26 Principal Benefits and Coverages (Covered Services) 27 26 Allergy Testing and Treatment Benefits 27 26 Ambulance Benefits 28 27 Ambulatory Surgery Center Benefits 28 27 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 28 27 Diabetes Care Benefits 29 28 Durable Medical Equipment Benefits 29 28 Emergency Room Benefits 30 29 Family Planning and Infertility Benefits 30 29 Home Health Care Benefits 31 30 Home Infusion and Home Injectable Therapy Benefits 31 30 Hospice Program Benefits 32 31 Hospital Benefits (Facility Services) 33 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 34 33 Mental Health and Substance Use Disorder Benefits 35 34 Orthotics Benefits 36 35 Outpatient X-Ray, Pathology and Laboratory 36 35 PKU Related Formulas and Special Food Products Benefits 36 35 Podiatric Benefits 37 36 Pregnancy and Maternity Care Benefits 37 36 Preventive Health Benefits 37 36 Professional (Physician) Benefits 38 37 Prosthetic Appliances Benefits 39 38 Reconstructive Surgery Benefits 39 Rehabilitation 38 Rehabilitative and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 39 38 Skilled Nursing Facility Benefits 40 39 Speech Therapy Benefits (Rehabilitation Rehabilitative and Habilitative Services) 40 39 Transplant Benefits 40 39 Urgent Services Benefits 41 40 Principal Limitations, Exceptions, Exclusions and Reductions 41 40 General Exclusions and Limitations 41 40 Medical Necessity Exclusion 44 43 Table of Contents Page Limitations for Duplicate Coverage 44 43 Exception for Other Coverage 45 Table of Contents Page 44 Claims Review 45 44 Reductions - Third Party Liability 45 44 Coordination of Benefits 46 45 Conditions of Coverage 47 46 Eligibility and Enrollment 47 46 Effective Date of Coverage 48 47 Premiums (Dues) 48 47 Grace Period 48 47 Plan Changes 48 Renewal of Group Health Service Contract 49 48 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 49 48 Extension of Benefits 51 50 Group Continuation Coverage 51 50 General Provisions 54 53 Plan Service Area 54 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 54 53 Right of Recovery 54 No Lifetime Benefit Maximum 55 54 No Annual Dollar Limits on Essential Health Benefits 55 54 Payment of Providers 55 54 Facilities 55 54 Independent Contractors 55 Non-Assignability 56 55 Plan Interpretation 56 55 Public Policy Participation Procedure 56 55 Confidentiality of Personal and Health Information 56 Access to Information 57 56 Grievance Process 57 56 Medical Services 57 56 Mental Health and Substance Use Disorder Services 58 57 External Independent Medical Review 58 57 Department of Managed Health Care Review 59 58 Shield Concierge 59 58 Definitions 59 Notice of the Availability of Language Assistance Services 72 70 Outpatient Prescription Drug Benefits 73 Rider 71 Chiropractic Services Rider 79 Contacting Blue Shield of California 82 83 Trio HMO Service Area Chart 83 84 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 98 99 Summary of Benefits Wesco Aircraft Hardware Corp Effective January 1, 2019 HMO Benefit Plan Wesco Aircraft Custom Trio HMO Zero Admit 10 City of Delano Effective July 1, 2018 HMO Benefit Plan Facility Deductible 25-20%/200 This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Benefit planbenefit Plan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage (EOC).1 Please read both documents carefully for details. Provider Network: Trio ACO HMO Network This benefit plan Plan uses a specific network of health care providersHealth Care Providers, called the Trio ACO HMO provider network. Medical groupsGroups, independent practice associations Independent Practice Associations (IPAs), and physicians Physicians in this network are called participating providersParticipating Providers. You must select a primary care physician Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this planPlan. You can find participating providers Participating Providers in this network at xxxxxxxxxxxx.xxx. Calendar Year Deductibles (CYD)2 Blue Shield of California is an independent member of the Blue Shield Association Calendar Year Deductibles (CYD)2 A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Benefit planbenefit Plan. Blue Shield pays for some Covered Services before the Calendar Year Deductible is met, as noted in the Benefits chart below. When using a participating provider3 Participating Provider3 Calendar year Year medical deductible Deductible Individual coverage $0 200 Family coverage $200: individual $400: Family Calendar Year Out-of-Pocket Maximum4 Family coverage $0: individual $0: family An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the EOC. When using a participating provider3 Participating Provider3 Individual coverage $1,000 3,000 Family coverage $1,0003,000: individual $2,0006,000: family Family No Lifetime Benefit Maximum Under this Benefit plan benefit Plan there is no dollar limit on the total amount Blue Shield will pay for Covered Services in a Member’s lifetime. A47045 A47058 (07/1801/19) 9 Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Preventive Health Services6 California Prenatal Screening Program $0 $0 Physician services Primary care office visit Trio+ specialist care office visit (self-referral) Other specialist care office visit (referred by PCP) Physician home visit Physician or surgeon services in an outpatient facility Outpatient Facility Physician or surgeon services in an inpatient facility $1025/visit $2025/visit $1025/visit $25/visit $0 $0 Other professional services Other practitioner office visit Includes nurses, nurse practitioners, physician assistants, and therapists. Teladoc consultation Family planning  Counseling, consulting, and education  Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure.  Tubal ligation  Vasectomy  Infertility services Podiatric services $1025/visit $5/consult $0 $0 $0 $0 50% $1025/visit Pregnancy and maternity care6 Physician office visits: prenatal and postnatal $0 Physician services for pregnancy termination $0 Emergency services and urgent care Emergency room services If admitted to the hospitalHospital, this payment for emergency room services does not apply. Instead, you pay the participating provider Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room physician Physician services $100/visit $0 Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Urgent care physician center services $1025/visit Inside your primary care physician’s service area, services must be provided or referred by your primary care physician or medical group/IPA. Services outside your primary care physician’s service area are also covered. Services inside your primary care physician’s service area not provided or referred by your primary care physician or medical group/IPA are not covered. Ambulance services This payment is for emergency or authorized transport. $100/transport Outpatient facility Facility services Ambulatory surgery center $0 Surgery Center 20%  Outpatient department of a hospitalHospital: surgery $0 20%  Outpatient department of a hospitalHospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies Inpatient facility services Hospital services and stay $0 Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.  Special transplant facility inpatient services $0  Physician inpatient services 20%  20%  $0 Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services Covered Services that are diagnostic, non- preventive health servicesPreventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test.  Laboratory center $0  Outpatient department of a hospital $0  California Prenatal Screening Program $0 Hospital X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center $0  Outpatient department of a hospital $0 Hospital Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG.  Office location $0  Outpatient department of a hospital $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Hospital Radiological and nuclear imaging services  Outpatient radiology center $0  Outpatient department of a hospital Hospital $0 Rehabilitation $0 $0 $0 $0 $0 $0 $150/test Benefits5 Your payment When using a Participating Provider3 CYD2 applies Rehabilitative and habilitative services Habilitative Services Includes physical therapyPhysical Therapy, occupational therapyOccupational Therapy, respiratory therapyRespiratory Therapy, and speech therapy Speech Therapy services. Office location $10/visit Outpatient department of a hospital Hospital $1025/visit $25/visit Durable medical equipment (DME) DME $0 Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices $50/item $0 $0 $0 Home health services Up to 100 visits per memberMember, per calendar yearCalendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible Deductible period, except hemophilia and home infusion nursing visits. Home health agency services $10/visit Includes home visits by a nurse, home health aideHome Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist. Home visits by an infusion nurse $10/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. $25/visit $25/visit $0 $0 $0 Skilled nursing facility Nursing Facility (SNF) services Up to 100 days per memberMember, per benefit periodBenefit Period, except when provided as part of a hospice Hospice program. All days count towards the limit, including days during any applicable deductible Deductible period and days in different SNFs during the calendar yearCalendar Year. Freestanding SNF $0 Hospital-based SNF $0 20%  20%  Hospice program services $0 Includes pre-hospice Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Benefits5 Your payment When using a participating provider3 CYD2 applies $0 Other services and supplies Diabetes care services  Devices, equipment, and supplies $0  Self-management training $10/visit Dialysis services $50/item $25/visit $0 Benefits5 Your payment When using a Participating Provider3 CYD2 applies PKU product formulas and special food products Special Food Products $0 Allergy serum 50% Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder benefits Benefits are provided through Blue Shield's mental health services administrator Mental Health Services Administrator (MHSA). When using a MHSA participating provider3 Participating Provider3 CYD2 applies Outpatient services Office visit, including physician Physician office visit $1025/visit Other outpatient services, including intensive outpatient care, behavioral health treatment Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility $0 setting, and office-based opioid treatment Partial hospitalization program Hospitalization Program $0 Psychological testing Testing $0 Inpatient services Physician inpatient services $0 Hospital services $0 20%  Residential care $0 Care 20%  Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the benefitsBenefits, limitations, and exclusions that apply to coverage under this benefit planPlan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio Access+ HMO Health Plan 16 15 How to Use This Health Plan 16 15 Selecting a Primary Care Physician 16 15 Primary Care Physician Relationship 17 16 Role of the Primary Care Physician 17 16 Obstetrical/Gynecological (OB/GYN) Physician Services 17 16 Referral to Specialty Services 17 16 Role of the Medical Group or IPA 18 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Access+ Specialist 17 Access+ Satisfaction 18 Trio+ Specialist 19 Trio+ Satisfaction 19 Mental Health and Substance Use Disorder Services 19 18 Continuity of Care 20 19 Second Medical Opinion 21 19 Urgent Services 21 19 Emergency Services 22 20 Claims for Emergency and Urgent Services 22 21 NurseHelp 24/7 sm 22 21 Life Referrals 24/7 23 21 Blue Shield Online 23 21 Health Education and Health Promotion Services 23 21 Timely Access to Care 23 21 Cost Sharing 23 22 Limitation of Liability 25 23 Out-of-Area Services 25 24 Inter-Plan Arrangements 25 24 BlueCard Program 25 24 Blue Shield Global Core 26 25 Utilization Management 27 25 Principal Benefits and Coverages (Covered Services) 27 26 Allergy Testing and Treatment Benefits 27 26 Ambulance Benefits 28 26 Ambulatory Surgery Center Benefits 28 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 28 26 Diabetes Care Benefits 29 27 Durable Medical Equipment Benefits 29 28 Emergency Room Benefits 30 28 Family Planning and Infertility Benefits 30 29 Home Health Care Benefits 31 29 Home Infusion and Home Injectable Therapy Benefits 31 30 Hospice Program Benefits 32 31 Hospital Benefits (Facility Services) 33 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 34 33 Mental Health and Substance Use Disorder Benefits 35 33 Orthotics Benefits 36 34 Outpatient X-Ray, Pathology and Laboratory 36 35 PKU Related Formulas and Special Food Products Benefits 36 35 Podiatric Benefits 37 35 Pregnancy and Maternity Care Benefits 37 35 Preventive Health Benefits 37 36 Professional (Physician) Benefits 38 36 Prosthetic Appliances Benefits 39 37 Reconstructive Surgery Benefits 39 Rehabilitation 38 Rehabilitative and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 39 38 Skilled Nursing Facility Benefits 40 38 Speech Therapy Benefits (Rehabilitation Rehabilitative and Habilitative Services) 40 38 Transplant Benefits 40 39 Urgent Services Benefits 41 39 Principal Limitations, Exceptions, Exclusions and Reductions 41 40 General Exclusions and Limitations 41 40 Medical Necessity Exclusion 44 43 Table of Contents Page Limitations for Duplicate Coverage 44 43 Exception for Other Coverage 45 Table of Contents Page 44 Claims Review 45 44 Reductions - Third Party Liability 45 44 Coordination of Benefits 46 45 Conditions of Coverage 47 46 Eligibility and Enrollment 47 46 Effective Date of Coverage 48 46 Premiums (Dues) 48 47 Grace Period 48 47 Plan Changes 48 47 Renewal of Group Health Service Contract 49 47 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 49 48 Extension of Benefits 51 49 Group Continuation Coverage 51 50 General Provisions 54 53 Plan Service Area 54 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 54 53 Right of Recovery 54 53 No Lifetime Benefit Maximum 55 53 No Annual Dollar Limits on Essential Health Benefits 55 53 Payment of Providers 55 53 Facilities 55 54 Independent Contractors 55 54 Non-Assignability 56 54 Plan Interpretation 56 54 Public Policy Participation Procedure 56 54 Confidentiality of Personal and Health Information 56 55 Access to Information 57 55 Grievance Process 57 56 Medical Services 57 56 Mental Health and Substance Use Disorder Services 58 56 External Independent Medical Review 58 57 Department of Managed Health Care Review 59 Shield Concierge 59 57 Customer Service 58 Definitions 59 58 Notice of the Availability of Language Assistance Services 72 70 Outpatient Prescription Drug Benefits 73 Rider 71 Chiropractic Services Rider 79 Contacting Blue Shield of California 82 Trio HMO Service Area Chart 83 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 98 85 Summary of Benefits Custom Trio HMO Zero Admit 10 City of Delano Wesco Aircraft Hardware Corp Effective July January 1, 2018 2019 HMO Benefit Plan Wesco Aircraft Custom Access+ HMO Facility Deductible 25-20%/200 This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Benefit planbenefit Plan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage (EOC).1 Please read both documents carefully for details. Provider Network: Trio ACO Access+ HMO Network This benefit plan Plan uses a specific network of health care providersHealth Care Providers, called the Trio ACO Access+ HMO provider network. Medical groupsGroups, independent practice associations Independent Practice Associations (IPAs), and physicians Physicians in this network are called participating providersParticipating Providers. You must select a primary care physician Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this planPlan. You can find participating providers Participating Providers in this network at xxxxxxxxxxxx.xxx. Calendar Year Deductibles (CYD)2 Blue Shield of California is an independent member of the Blue Shield Association Calendar Year Deductibles (CYD)2 A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Benefit planbenefit Plan. Blue Shield pays for some Covered Services before the Calendar Year Deductible is met, as noted in the Benefits chart below. When using a participating provider3 Participating Provider3 Calendar year Year medical deductible Deductible Individual coverage $0 200 Family coverage $200: individual $400: Family Calendar Year Out-of-Pocket Maximum4 Family coverage $0: individual $0: family An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the EOC. When using a participating provider3 Participating Provider3 Individual coverage $1,000 3,000 Family coverage $1,0003,000: individual $2,0006,000: family Family No Lifetime Benefit Maximum Under this Benefit plan benefit Plan there is no dollar limit on the total amount Blue Shield will pay for Covered Services in a Member’s lifetime. A47045 A44607 (07/1801/19) 9 Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Preventive Health Services6 California Prenatal Screening Program $0 $0 Physician services Primary care office visit Trio+ Access+ specialist care office visit (self-referral) Other specialist care office visit (referred by PCP) Physician home visit Physician or surgeon services in an outpatient facility Outpatient Facility Physician or surgeon services in an inpatient facility $1025/visit $2040/visit $1025/visit $25/visit $0 $0 Other professional services Other practitioner office visit Includes nurses, nurse practitioners, physician assistants, and therapists. Teladoc consultation Family planning  Counseling, consulting, and education  Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure.  Tubal ligation  Vasectomy  Infertility services Podiatric services $1025/visit $5/consult $0 $0 $0 $0 50% $1025/visit Pregnancy and maternity care6 Physician office visits: prenatal and postnatal $0 Physician services for pregnancy termination $0 Emergency services and urgent care Emergency room services If admitted to the hospitalHospital, this payment for emergency room services does not apply. Instead, you pay the participating provider Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room physician Physician services $100/visit $0 Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Urgent care physician center services $1025/visit Inside your primary care physician’s service area, services must be provided or referred by your primary care physician or medical group/IPA. Services outside your primary care physician’s service area are also covered. Services inside your primary care physician’s service area not provided or referred by your primary care physician or medical group/IPA are not covered. Ambulance services This payment is for emergency or authorized transport. $100/transport Outpatient facility Facility services Ambulatory surgery center $0 Surgery Center 20%  Outpatient department of a hospitalHospital: surgery $0 20%  Outpatient department of a hospitalHospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies Inpatient facility services Hospital services and stay $0 Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.  Special transplant facility inpatient services $0  Physician inpatient services 20%  20%  $0 Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services Covered Services that are diagnostic, non- preventive health servicesPreventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test.  Laboratory center $0  Outpatient department of a hospital $0  California Prenatal Screening Program $0 Hospital X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center $0  Outpatient department of a hospital $0 Hospital Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG.  Office location $0  Outpatient department of a hospital $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Hospital Radiological and nuclear imaging services  Outpatient radiology center $0  Outpatient department of a hospital Hospital $0 Rehabilitation $0 $0 $0 $0 $0 $0 $150/test Benefits5 Your payment When using a Participating Provider3 CYD2 applies Rehabilitative and habilitative services Habilitative Services Includes physical therapyPhysical Therapy, occupational therapyOccupational Therapy, respiratory therapyRespiratory Therapy, and speech therapy Speech Therapy services. Office location $10/visit Outpatient department of a hospital Hospital $1025/visit $25/visit Durable medical equipment (DME) DME $0 Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices $50/item $0 $0 $0 Home health services Up to 100 visits per memberMember, per calendar yearCalendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible Deductible period, except hemophilia and home infusion nursing visits. Home health agency services $10/visit Includes home visits by a nurse, home health aideHome Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist. Home visits by an infusion nurse $10/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. $25/visit $25/visit $0 $0 $0 Skilled nursing facility Nursing Facility (SNF) services Up to 100 days per memberMember, per benefit periodBenefit Period, except when provided as part of a hospice Hospice program. All days count towards the limit, including days during any applicable deductible Deductible period and days in different SNFs during the calendar yearCalendar Year. Freestanding SNF $0 Hospital-based SNF $0 20%  20%  Hospice program services $0 Includes pre-hospice Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Benefits5 Your payment When using a participating provider3 CYD2 applies $0 Other services and supplies Diabetes care services  Devices, equipment, and supplies $0  Self-management training $10/visit Dialysis services $50/item $25/visit $0 Benefits5 Your payment When using a Participating Provider3 CYD2 applies PKU product formulas and special food products Special Food Products $0 Allergy serum 50% Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder benefits Benefits are provided through Blue Shield's mental health services administrator Mental Health Services Administrator (MHSA). When using a MHSA participating provider3 Participating Provider3 CYD2 applies Outpatient services Office visit, including physician Physician office visit $1025/visit Other outpatient services, including intensive outpatient care, behavioral health treatment Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility $0 setting, and office-based opioid treatment Partial hospitalization program Hospitalization Program $0 Psychological testing Testing $0 Inpatient services Physician inpatient services $0 Hospital services $0 20%  Residential care $0 Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the benefits, limitations, and exclusions that apply to coverage under this benefit plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.Care 20%  Notes

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio Access+ HMO Health Plan 16 15 How to Use This Health Plan 16 15 Selecting a Primary Care Physician 16 15 Primary Care Physician Relationship 17 16 Role of the Primary Care Physician 17 16 Obstetrical/Gynecological (OB/GYN) Physician Services 17 16 Referral to Specialty Services 17 16 Role of the Medical Group or IPA 18 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Access+ Specialist 17 Access+ Satisfaction 18 Trio+ Specialist 19 Trio+ Satisfaction 19 Mental Health and Substance Use Disorder Services 19 18 Continuity of Care 20 19 Second Medical Opinion 21 19 Urgent Services 21 19 Emergency Services 22 20 Claims for Emergency and Urgent Services 22 21 NurseHelp 24/7 sm 22 21 Life Referrals 24/7 23 21 Blue Shield Online 23 21 Health Education and Health Promotion Services 23 21 Timely Access to Care 23 21 Cost Sharing 23 22 Limitation of Liability 25 23 Out-of-Area Services 25 24 Inter-Plan Arrangements 25 24 BlueCard Program 25 24 Blue Shield Global Core 26 25 Utilization Management 27 25 Principal Benefits and Coverages (Covered Services) 27 26 Allergy Testing and Treatment Benefits 27 26 Ambulance Benefits 28 26 Ambulatory Surgery Center Benefits 28 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 28 26 Diabetes Care Benefits 29 27 Durable Medical Equipment Benefits 29 28 Emergency Room Benefits 30 28 Family Planning and Infertility Benefits 30 29 Home Health Care Benefits 31 29 Home Infusion and Home Injectable Therapy Benefits 31 30 Hospice Program Benefits 32 31 Hospital Benefits (Facility Services) 33 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 34 33 Mental Health and Substance Use Disorder Benefits 35 33 Orthotics Benefits 36 34 Outpatient X-Ray, Pathology and Laboratory 36 35 PKU Related Formulas and Special Food Products Benefits 36 35 Podiatric Benefits 37 35 Pregnancy and Maternity Care Benefits 37 35 Preventive Health Benefits 37 36 Professional (Physician) Benefits 38 36 Prosthetic Appliances Benefits 39 37 Reconstructive Surgery Benefits 39 38 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 39 38 Skilled Nursing Facility Benefits 40 38 Speech Therapy Benefits (Rehabilitation and Habilitative Services) 40 38 Transplant Benefits 40 39 Urgent Services Benefits 41 39 Principal Limitations, Exceptions, Exclusions and Reductions 41 40 General Exclusions and Limitations 41 40 Medical Necessity Exclusion 44 43 Limitations for Duplicate Coverage 44 43 Exception for Other Coverage 45 44 Table of Contents Page Claims Review 45 44 Reductions - Third Party Liability 45 44 Coordination of Benefits 46 45 Conditions of Coverage 47 45 Eligibility and Enrollment 47 45 Effective Date of Coverage 48 46 Premiums (Dues) 48 47 Grace Period 48 47 Plan Changes 48 47 Renewal of Group Health Service Contract 49 47 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 49 47 Extension of Benefits 51 49 Group Continuation Coverage 51 49 General Provisions 54 53 Plan Service Area 54 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 54 53 Right of Recovery 54 53 No Lifetime Benefit Maximum 55 53 No Annual Dollar Limits on Essential Health Benefits 55 53 Payment of Providers 55 53 Facilities 55 54 Independent Contractors 55 54 Non-Assignability 56 54 Plan Interpretation 56 54 Public Policy Participation Procedure 56 54 Confidentiality of Personal and Health Information 56 55 Access to Information 57 55 Grievance Process 57 55 Medical Services 57 55 Mental Health and Substance Use Disorder Services 58 56 External Independent Medical Review 58 57 Department of Managed Health Care Review 59 Shield Concierge 59 57 Customer Service 58 Definitions 59 58 Notice of the Availability of Language Assistance Services 72 70 Outpatient Prescription Drug Benefits 73 71 Acupuncture and Chiropractic Services 79 78 Contacting Blue Shield of California 82 Trio HMO Service Area Chart 83 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 98 83 Summary of Benefits Custom Trio County of Ventura Access+ HMO Zero Admit 10 City County of Delano Ventura Effective July 1December 30, 2018 HMO Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services covered services under this Blue Shield of California Benefit benefit plan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage (EOC).1 Please read both documents carefully for details. Provider Network: Trio ACO Access+ HMO Network This benefit plan uses a specific network of health care providers, called the Trio ACO Access+ HMO provider network. Medical groups, independent practice associations (IPAs), and physicians in this network are called participating providers. You must select a primary care physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this plan. You can find participating providers in this network at xxxxxxxxxxxx.xxx. Calendar Year Deductibles (CYD)2 Blue Shield of California is an independent member of the Blue Shield Association A Calendar Year Deductible calendar year deductible (CYD) is the amount a Member member pays each Calendar Year calendar year before Blue Shield pays for Covered Services covered services under the Benefit benefit plan. When using a participating provider3 Calendar year medical deductible Individual coverage $0 Calendar Year Out-of-Pocket Maximum4 Family coverage $0: individual $0: family An Outout-of-Pocket Maximum pocket maximum is the most a Member member will pay for Covered Services covered services each Calendar Yearcalendar year. Any exceptions are listed in the EOC. When using a participating provider3 Individual coverage $1,000 1,500 Family coverage $1,0001,500: individual $2,0003,000: family No Lifetime Benefit Maximum Under this Benefit benefit plan there is no dollar limit on the total amount Blue Shield will pay for Covered Services covered services in a Membermember’s lifetime. A47045 A16203 (07/1812/18) 9 Benefits5 Your payment When using a participating provider3 CYD2 applies Preventive Health Services6 $0 Physician services Primary care office visit Trio+ Access+ specialist care office visit Other specialist care office visit Physician home visit Physician or surgeon services in an outpatient facility Physician or surgeon services in an inpatient facility $1035/visit $2040/visit $1035/visit $2550/visit $0 $0 Other professional services Other practitioner office visit Includes nurses, nurse practitioners, and therapists. Teladoc consultation Family planning  • Counseling, consulting, and education  • Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure.  • Tubal ligation  • Vasectomy  • Infertility services Podiatric services $1035/visit $5/consult $0 $0 $0 $0 50% $1035/visit Pregnancy and maternity care6 Physician office visits: prenatal and postnatal $0 Physician services for pregnancy termination $0 $0 Emergency services and urgent care Emergency room services If admitted to the hospital, this payment for emergency room services does not apply. Instead, you pay the participating provider payment under Inpatient facility services/ Hospital services and stay. Emergency room physician services $100/visit $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Ambulance services $100/transport Urgent care physician services $10/visit Inside your primary care physician’s service area, services must be provided or referred by your primary care physician or medical group/IPA. Services outside your primary care physician’s service area are also covered. Services inside your primary care physician’s service area not provided or referred by your primary care physician or medical group/IPA are not covered. Ambulance services $10035/transport visit Outpatient facility services Ambulatory surgery center $0 Outpatient department of a hospital: surgery $0 Outpatient department of a hospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies $250/surgery $250/surgery $0 Inpatient facility services Hospital services and stay $0 Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.  • Special transplant facility inpatient services $0  • Physician inpatient services $500/admission $500/admission $0 Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services that are diagnostic, non- preventive health services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test.  • Laboratory center $0  • Outpatient department of a hospital $0  • California Prenatal Screening Program $0 X-ray and imaging services Includes diagnostic mammography.  • Outpatient radiology center $0  • Outpatient department of a hospital $0 Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG.  • Office location $0  Outpatient department of a hospital $0 $0 $0 $0 $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Radiological and nuclear imaging services  Outpatient radiology center $0  • Outpatient department of a hospital $0 Radiological and nuclear imaging services • Outpatient radiology center $100/test • Outpatient department of a hospital $100/test Rehabilitation and habilitative services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location $1035/visit Outpatient department of a hospital $1035/visit Durable medical equipment (DME) DME $0 50% Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices $0 Home health services Up to 100 visits per member, per calendar year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible period, except hemophilia and home infusion nursing visits. Home health agency services $1035/visit Includes home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. Home visits by an infusion nurse $1035/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. Skilled nursing facility (SNF) services Up to 100 days per member, per benefit period, except when provided as part of a hospice program. All days count towards the limit, including days during any applicable deductible period and days in different SNFs during the calendar year. Freestanding SNF $0 Hospital-based SNF $0 Hospice program services $0 Includes pre-hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Benefits5 Your payment When using a participating provider3 CYD2 applies Other services and supplies Diabetes care services  • Devices, equipment, and supplies $0  20% • Self-management training $1035/visit Dialysis services $0 PKU product formulas and special food products $0 Allergy serum 50% Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder benefits are provided When using a MHSA through Blue Shield's mental health services administrator (MHSA). When using a MHSA participating provider3 CYD2 applies Outpatient services Office visit, including physician office visit $1035/visit Other outpatient services, including intensive outpatient care, behavioral health treatment for pervasive developmental disorder $0 or autism in an office setting, home, or other non-institutional facility $0 setting, and office-based opioid treatment Partial hospitalization program $0 Psychological testing $0 Inpatient services Physician inpatient services $0 Hospital services $0 500/admission Residential care $0 Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the benefits, limitations, and exclusions that apply to coverage under this benefit plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.500/admission Notes

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 16 15 How to Use This Health Plan 16 15 Selecting a Primary Care Physician 16 15 Primary Care Physician Relationship 17 16 Role of the Primary Care Physician 17 16 Obstetrical/Gynecological (OB/GYN) Physician Services 17 16 Referral to Specialty Services 17 16 Role of the Medical Group or IPA 18 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Specialist 19 Trio+ Satisfaction 19 18 Mental Health and Substance Use Disorder Services 19 18 Continuity of Care 20 19 Second Medical Opinion 21 20 Urgent Services 21 20 Emergency Services 22 21 Claims for Emergency and Urgent Services 22 21 NurseHelp 24/7 sm 22 21 Life Referrals 24/7 23 22 Blue Shield Online 23 22 Health Education and Health Promotion Services 23 22 Timely Access to Care 23 22 Cost Sharing 23 22 Limitation of Liability 25 24 Out-of-Area Services 25 24 Inter-Plan Arrangements 25 24 BlueCard Program 25 24 Blue Shield Global Core 26 25 Utilization Management 27 26 Principal Benefits and Coverages (Covered Services) 27 26 Allergy Testing and Treatment Benefits 27 26 Ambulance Benefits 28 27 Ambulatory Surgery Center Benefits 28 27 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 28 27 Diabetes Care Benefits 29 28 Durable Medical Equipment Benefits 29 28 Emergency Room Benefits 30 29 Family Planning and Infertility Benefits 30 29 Home Health Care Benefits 31 30 Home Infusion and Home Injectable Therapy Benefits 31 30 Hospice Program Benefits 32 31 Hospital Benefits (Facility Services) 33 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 34 33 Mental Health and Substance Use Disorder Benefits 35 34 Orthotics Benefits 36 35 Outpatient X-Ray, Pathology and Laboratory 36 35 PKU Related Formulas and Special Food Products Benefits 36 35 Podiatric Benefits 37 36 Pregnancy and Maternity Care Benefits 37 36 Preventive Health Benefits 37 36 Professional (Physician) Benefits 38 37 Prosthetic Appliances Benefits 39 38 Reconstructive Surgery Benefits 39 Rehabilitation 38 Rehabilitative and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 39 38 Skilled Nursing Facility Benefits 40 39 Speech Therapy Benefits (Rehabilitation Rehabilitative and Habilitative Services) 40 39 Transplant Benefits 40 39 Urgent Services Benefits 41 40 Principal Limitations, Exceptions, Exclusions and Reductions 41 40 General Exclusions and Limitations 41 40 Medical Necessity Exclusion 44 43 Table of Contents Page Limitations for Duplicate Coverage 44 43 Exception for Other Coverage 45 Table of Contents Page 44 Claims Review 45 44 Reductions - Third Party Liability 45 44 Coordination of Benefits 46 45 Conditions of Coverage 47 46 Eligibility and Enrollment 47 46 Effective Date of Coverage 48 47 Premiums (Dues) 48 47 Grace Period 48 47 Plan Changes 48 Renewal of Group Health Service Contract 49 48 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 49 48 Extension of Benefits 51 50 Group Continuation Coverage 51 50 General Provisions 54 53 Plan Service Area 54 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 54 53 Right of Recovery 54 No Lifetime Benefit Maximum 55 54 No Annual Dollar Limits on Essential Health Benefits 55 54 Payment of Providers 55 54 Facilities 55 54 Independent Contractors 55 Non-Assignability 56 55 Plan Interpretation 56 55 Public Policy Participation Procedure 56 55 Confidentiality of Personal and Health Information 56 Access to Information 57 56 Grievance Process 57 56 Medical Services 57 56 Mental Health and Substance Use Disorder Services 58 57 External Independent Medical Review 58 57 Department of Managed Health Care Review 59 58 Shield Concierge 59 58 Definitions 59 Notice of the Availability of Language Assistance Services 72 70 Outpatient Prescription Drug Benefits 73 Rider 71 Chiropractic Services Rider 79 Contacting Blue Shield of California 82 83 Trio HMO Service Area Chart 83 84 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 98 99 Summary of Benefits Wesco Aircraft Hardware Corp Effective January 1, 2019 HMO Benefit Plan Wesco Aircraft Custom Trio HMO Zero Admit 10 City of Delano Effective July 1, 2018 HMO Benefit Plan Facility Deductible 25-20%/200 This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Benefit planbenefit Plan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage (EOC).1 Please read both documents carefully for details. Provider Network: Trio ACO HMO Network This benefit plan Plan uses a specific network of health care providersHealth Care Providers, called the Trio ACO HMO provider network. Medical groupsGroups, independent practice associations Independent Practice Associations (IPAs), and physicians Physicians in this network are called participating providersParticipating Providers. You must select a primary care physician Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this planPlan. You can find participating providers Participating Providers in this network at xxxxxxxxxxxx.xxx. Calendar Year Deductibles (CYD)2 Blue Shield of California is an independent member of the Blue Shield Association Calendar Year Deductibles (CYD)2 A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Benefit planbenefit Plan. Blue Shield pays for some Covered Services before the Calendar Year Deductible is met, as noted in the Benefits chart below. When using a participating provider3 Participating Provider3 Calendar year Year medical deductible Deductible Individual coverage $0 200 Family coverage $200: individual $400: Family Calendar Year Out-of-Pocket Maximum4 Family coverage $0: individual $0: family An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the EOC. When using a participating provider3 Participating Provider3 Individual coverage $1,000 3,000 Family coverage $1,0003,000: individual $2,0006,000: family Family No Lifetime Benefit Maximum Under this Benefit plan benefit Plan there is no dollar limit on the total amount Blue Shield will pay for Covered Services in a Member’s lifetime. A47045 A47058 (07/1801/19) 9 Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Preventive Health Services6 California Prenatal Screening Program $0 $0 Physician services Primary care office visit Trio+ specialist care office visit (self-referral) Other specialist care office visit (referred by PCP) Physician home visit Physician or surgeon services in an outpatient facility Outpatient Facility Physician or surgeon services in an inpatient facility $1025/visit $2025/visit $1025/visit $25/visit $0 $0 Other professional services Other practitioner office visit Includes nurses, nurse practitioners, physician assistants, and therapists. Teladoc consultation Family planning  • Counseling, consulting, and education  • Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure.  • Tubal ligation  • Vasectomy  • Infertility services Podiatric services $1025/visit $5/consult $0 $0 $0 $0 50% $1025/visit Pregnancy and maternity care6 Physician office visits: prenatal and postnatal $0 Physician services for pregnancy termination $0 $0 Emergency services and urgent care Emergency room services If admitted to the hospitalHospital, this payment for emergency room services does not apply. Instead, you pay the participating provider Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room physician Physician services $100/visit $0 Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Urgent care physician center services $1025/visit Inside your primary care physician’s service area, services must be provided or referred by your primary care physician or medical group/IPA. Services outside your primary care physician’s service area are also covered. Services inside your primary care physician’s service area not provided or referred by your primary care physician or medical group/IPA are not covered. Ambulance services This payment is for emergency or authorized transport. $100/transport Outpatient facility Facility services Ambulatory surgery center $0 Surgery Center 20% ✔ Outpatient department of a hospitalHospital: surgery $0 20% ✔ Outpatient department of a hospitalHospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies $0 Inpatient facility services Hospital services and stay $0 Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.  • Special transplant facility inpatient services $0  • Physician inpatient services 20% ✔ 20% ✔ $0 Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services Covered Services that are diagnostic, non- preventive health servicesPreventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test.  • Laboratory center $0  • Outpatient department of a hospital $0  California Prenatal Screening Program $0 Hospital X-ray and imaging services Includes diagnostic mammography.  • Outpatient radiology center $0  • Outpatient department of a hospital $0 Hospital Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG.  • Office location $0  • Outpatient department of a hospital Hospital Radiological and nuclear imaging services • Outpatient radiology center • Outpatient department of a Hospital $0 $0 $0 $0 $0 $0 $0 $150/test Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Radiological Rehabilitative and nuclear imaging services  Outpatient radiology center $0  Habilitative Services Includes Physical Therapy, Occupational Therapy, Respiratory Therapy, and Speech Therapy services. Office location Outpatient department of a hospital Hospital $0 Rehabilitation and habilitative services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location $1025/visit Outpatient department of a hospital $1025/visit Durable medical equipment (DME) DME $0 Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices $50/item $0 $0 $0 Home health services Up to 100 visits per memberMember, per calendar yearCalendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible Deductible period, except hemophilia and home infusion nursing visits. Home health agency services $10/visit Includes home visits by a nurse, home health aideHome Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist. Home visits by an infusion nurse $10/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. $25/visit $25/visit $0 $0 $0 Skilled nursing facility Nursing Facility (SNF) services Up to 100 days per memberMember, per benefit periodBenefit Period, except when provided as part of a hospice Hospice program. All days count towards the limit, including days during any applicable deductible Deductible period and days in different SNFs during the calendar yearCalendar Year. Freestanding SNF $0 Hospital-based SNF $0 20% ✔ 20% ✔ Hospice program services $0 Includes pre-hospice Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Benefits5 Your payment When using a participating provider3 CYD2 applies $0 Other services and supplies Diabetes care services  • Devices, equipment, and supplies $0  • Self-management training $10/visit Dialysis services $50/item $25/visit $0 Benefits5 Your payment When using a Participating Provider3 CYD2 applies PKU product formulas and special food products Special Food Products $0 Allergy serum 50% Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder benefits Benefits are provided through Blue Shield's mental health services administrator Mental Health Services Administrator (MHSA). When using a MHSA participating provider3 Participating Provider3 CYD2 applies Outpatient services Office visit, including physician Physician office visit $1025/visit Other outpatient services, including intensive outpatient care, behavioral health treatment Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility $0 setting, and office-based opioid treatment $0 Partial hospitalization program Hospitalization Program $0 Psychological testing Testing $0 Inpatient services Physician inpatient services $0 Hospital services $0 20% ✔ Residential care $0 Care 20% ✔ Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the benefitsBenefits, limitations, and exclusions that apply to coverage under this benefit planPlan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio Access+ HMO Health Plan 16 15 How to Use This Health Plan 16 15 Selecting a Primary Care Physician 16 15 Primary Care Physician Relationship 17 16 Role of the Primary Care Physician 17 16 Obstetrical/Gynecological (OB/GYN) Physician Services 17 16 Referral to Specialty Services 17 16 Role of the Medical Group or IPA 18 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Access+ Specialist 17 Access+ Satisfaction 18 Trio+ Specialist 19 Trio+ Satisfaction 19 Mental Health and Substance Use Disorder Services 19 18 Continuity of Care 20 19 Second Medical Opinion 21 19 Urgent Services 21 19 Emergency Services 22 20 Claims for Emergency and Urgent Services 22 21 NurseHelp 24/7 sm 22 21 Life Referrals 24/7 23 21 Blue Shield Online 23 21 Health Education and Health Promotion Services 23 21 Timely Access to Care 23 21 Cost Sharing 23 22 Limitation of Liability 25 23 Out-of-Area Services 25 24 Inter-Plan Arrangements 25 24 BlueCard Program 25 24 Blue Shield Global Core 26 25 Utilization Management 27 25 Principal Benefits and Coverages (Covered Services) 27 25 Allergy Testing and Treatment Benefits 27 26 Ambulance Benefits 28 26 Ambulatory Surgery Center Benefits 28 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 28 26 Diabetes Care Benefits 29 27 Durable Medical Equipment Benefits 29 28 Emergency Room Benefits 30 28 Family Planning and Infertility Benefits 30 29 Home Health Care Benefits 31 29 Home Infusion and Home Injectable Therapy Benefits 31 30 Hospice Program Benefits 32 31 Hospital Benefits (Facility Services) 33 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 34 33 Mental Health and Substance Use Disorder Benefits 35 33 Orthotics Benefits 36 34 Outpatient X-Ray, Pathology and Laboratory 36 35 PKU Related Formulas and Special Food Products Benefits 36 35 Podiatric Benefits 37 35 Pregnancy and Maternity Care Benefits 37 35 Preventive Health Benefits 37 35 Professional (Physician) Benefits 38 36 Prosthetic Appliances Benefits 39 37 Reconstructive Surgery Benefits 39 Rehabilitation 37 Rehabilitative and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 39 38 Skilled Nursing Facility Benefits 40 38 Speech Therapy Benefits (Rehabilitation Rehabilitative and Habilitative Services) 40 38 Transplant Benefits 40 38 Urgent Services Benefits 41 39 Principal Limitations, Exceptions, Exclusions and Reductions 41 40 General Exclusions and Limitations 41 40 Medical Necessity Exclusion 44 43 Table of Contents Page Limitations for Duplicate Coverage 44 43 Exception for Other Coverage 45 Table of Contents Page 43 Claims Review 45 44 Reductions - Third Party Liability 45 44 Coordination of Benefits 46 45 Conditions of Coverage 47 45 Eligibility and Enrollment 47 45 Effective Date of Coverage 48 46 Premiums (Dues) 48 47 Grace Period 48 47 Plan Changes 48 47 Renewal of Group Health Service Contract 49 47 Termination of Benefits (Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 49 Coverage) 47 Extension of Benefits 51 49 Group Continuation Coverage 51 49 General Provisions 54 52 Plan Service Area 54 52 Liability of Subscribers in the Event of Non-Payment by Blue Shield 54 53 Right of Recovery 54 53 No Lifetime Benefit Maximum 55 53 No Annual Dollar Limits on Essential Health Benefits 55 53 Payment of Providers 55 53 Facilities 55 53 Independent Contractors 55 54 Non-Assignability 56 54 Plan Interpretation 56 54 Public Policy Participation Procedure 56 54 Confidentiality of Personal and Health Information 56 55 Access to Information 57 55 Grievance Process 57 55 Medical Services 57 55 Mental Health and Substance Use Disorder Services 58 56 External Independent Medical Review 58 57 Department of Managed Health Care Review 59 Shield Concierge 59 57 Customer Service 57 Definitions 59 58 Notice of the Availability of Language Assistance Services 72 70 Acupuncture and Chiropractic Services Rider 71 Outpatient Prescription Drug Benefits 73 Chiropractic Services 79 Rider 74 Contacting Blue Shield of California 82 Trio HMO Service Area Chart 83 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 98 Summary of Benefits Custom Trio Access+ HMO® Facility Deductible 30-30%/2000 Group Plan HMO Zero Admit 10 City of Delano Effective July 1, 2018 HMO Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Benefit planPlan. It is only a summary and it is included as part of the contract for health care coverage, called the Evidence of Coverage (EOC).1 Please read both documents carefully for details. Medical Provider Network: Trio ACO Access+ HMO Network This benefit plan Plan uses a specific network of health care providersHealth Care Providers, called the Trio ACO Access+ HMO provider network. Medical groupsGroups, independent practice associations Independent Practice Associations (IPAs), and physicians Physicians in this network are called participating providersParticipating Providers. You must select a primary care physician Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this planPlan. You can find participating providers Participating Providers in this network at xxxxxxxxxxxx.xxx. Calendar Year Deductibles (CYD)2 Blue Shield of California is an independent member of the Blue Shield Association A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Benefit planPlan. Blue Shield pays for some Covered Services before the Calendar Year Deductible is met, as noted in the Benefits chart below. Blue Shield of California is an independent member of the Blue Shield Association When using a participating provider3 Participating Provider3 Calendar year Year medical deductible Deductible Individual coverage $0 2,000 Family coverage $2,000: individual $4,000: Family Calendar Year Out-of-Pocket Maximum4 Family coverage $0: individual $0: family An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the EOC. When using a participating provider3 Participating Provider3 Individual coverage $1,000 3,500 Family coverage $1,0003,500: individual $2,0007,000: family Family No Annual or Lifetime Benefit Maximum Dollar Limit Under this Benefit plan Plan there is no annual or lifetime dollar limit on the total amount Blue Shield will pay for Covered Services in a Member’s lifetimeServices. A47045 A44608 (07/1801/20) 9 Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Preventive Health Services6 Preventive Health Services California Prenatal Screening Program $0 $0 Physician services Primary care office visit Trio+ Access+ specialist care office visit (self-referral) Other specialist care office visit (referred by PCP) Physician home visit Physician or surgeon services in an outpatient facility Physician or surgeon services in an inpatient facility $1030/visit $2045/visit $1030/visit $2530/visit $0 $0 Other professional services Other practitioner office visit Includes nurses, nurse practitioners, physician assistants, and therapists. Teladoc consultation Family planning  • Counseling, consulting, and education  • Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure.  • Tubal ligation  • Vasectomy  Infertility services Podiatric services $1030/visit $5/consult $0 $0 $0 $0 50% $1030/visit Pregnancy and maternity care6 Physician office visits: prenatal and postnatal $0 Physician services for pregnancy termination $0 $0 Emergency services and urgent care Emergency room services If admitted to the hospitalHospital, this payment for emergency room services does not apply. Instead, you pay the participating provider Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room physician Physician services $100150/visit $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Urgent care physician center services $1030/visit Inside your primary care physician’s service area, services must be provided or referred by your primary care physician or medical group/IPA. Services outside your primary care physician’s service area are also covered. Services inside your primary care physician’s service area not provided or referred by your primary care physician or medical group/IPA are not covered. Ambulance services This payment is for emergency or authorized transport. $100/transport Outpatient facility services Ambulatory surgery center $0 Surgery Center 20% ✔ Benefits5 Your payment When using a Participating Provider3 CYD2 applies Outpatient department Department of a hospitalHospital: surgery $0 Outpatient department Department of a hospitalHospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies 30% $0 ✔ Inpatient facility services Hospital services and stay $0 Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.  • Special transplant facility inpatient services $0  • Physician inpatient services 30% 30% $0 ✔ ✔ Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services Covered Services that are diagnostic, non- preventive health servicesPreventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test.  • Laboratory center $0  • Outpatient department Department of a hospital $0  California Prenatal Screening Program $0 Hospital X-ray and imaging services Includes diagnostic mammography.  • Outpatient radiology center $0  • Outpatient department Department of a hospital $0 Hospital Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG.  • Office location • Outpatient Department of a Hospital Radiological and nuclear imaging services • Outpatient radiology center • Outpatient Department of a Hospital $0  $0 $0 $0 $0 $0 $0 $0 Rehabilitative and Habilitative Services Includes Physical Therapy, Occupational Therapy, Respiratory Therapy, and Speech Therapy services. Office location Outpatient department Department of a hospital Hospital $0 30/visit $30/visit Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Radiological and nuclear imaging services  Outpatient radiology center $0  Outpatient department of a hospital $0 Rehabilitation and habilitative services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location $10/visit Outpatient department of a hospital $10/visit Durable medical equipment (DME) DME $0 Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices 50% $0 $0 $0 Home health care services Up to 100 visits per memberMember, per calendar yearCalendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible Deductible period, except hemophilia and home infusion nursing visits. Home health agency services $10/visit Includes home visits by a nurse, home health aideHome Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. $30/visit Home infusion and home injectable therapy services Home infusion agency services Includes home infusion drugs and medical supplies. Home visits by an infusion nurse $10/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. $0 $30/visit $0 Skilled nursing facility Nursing Facility (SNF) services Up to 100 days per memberMember, per benefit periodBenefit Period, except when provided as part of a hospice Hospice program. All days count towards the limit, including days during any applicable deductible Deductible period and days in different SNFs during the calendar yearCalendar Year. Freestanding SNF $0 Hospital-based SNF $0 30% 30% ✔✔ Hospice program services $0 Includes pre-hospice Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Benefits5 Your payment When using a participating provider3 CYD2 applies $0 Other services and supplies Diabetes care services  • Devices, equipment, and supplies $0  • Self-management training $10/visit Dialysis services $0 PKU product formulas and special food products Special Food Products Allergy serum billed separately from an office visit 20% $30/visit $0 Allergy serum $0 50% Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder benefits Benefits are provided through Blue Shield's mental health services administrator Mental Health Service Administrator (MHSA). When using a MHSA participating provider3 Participating Provider3 CYD2 applies Outpatient services Office visit, including physician Physician office visit $1030/visit Other outpatient services, including intensive outpatient care, behavioral health treatment electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility $0 setting, and office-based opioid treatment $0 Partial hospitalization program Hospitalization Program $0 Psychological testing Testing $0 Inpatient services Physician inpatient services $0 Hospital services $0 30% ✔ Residential care $0 Care 30% ✔ Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the benefitsBenefits, limitations, and exclusions that apply to coverage under this benefit planPlan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio Access+ HMO Health Plan 16 15 How to Use This Health Plan 16 15 Selecting a Primary Care Physician 16 15 Primary Care Physician Relationship 17 16 Role of the Primary Care Physician 17 16 Obstetrical/Gynecological (OB/GYN) Physician Services 17 16 Referral to Specialty Services 17 16 Role of the Medical Group or IPA 18 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Access+ Specialist 17 Access+ Satisfaction 18 Trio+ Specialist 19 Trio+ Satisfaction 19 Mental Health and Substance Use Disorder Services 19 18 Continuity of Care 20 19 Second Medical Opinion 21 19 Urgent Services 21 19 Emergency Services 22 20 Claims for Emergency and Urgent Services 22 21 NurseHelp 24/7 sm 22 21 Life Referrals 24/7 23 21 Blue Shield Online 23 21 Health Education and Health Promotion Services 23 21 Timely Access to Care 23 21 Cost Sharing 23 22 Limitation of Liability 25 23 Out-of-Area Services 25 24 Inter-Plan Arrangements 25 24 BlueCard Program 25 24 Blue Shield Global Core 26 25 Utilization Management 27 25 Principal Benefits and Coverages (Covered Services) 27 25 Allergy Testing and Treatment Benefits 27 26 Ambulance Benefits 28 26 Ambulatory Surgery Center Benefits 28 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 28 26 Diabetes Care Benefits 29 27 Durable Medical Equipment Benefits 29 28 Emergency Room Benefits 30 28 Family Planning and Infertility Benefits 30 29 Home Health Care Benefits 31 29 Home Infusion and Home Injectable Therapy Benefits 31 30 Hospice Program Benefits 32 31 Hospital Benefits (Facility Services) 33 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 34 33 Mental Health and Substance Use Disorder Benefits 35 33 Orthotics Benefits 36 34 Outpatient X-Ray, Pathology and Laboratory 36 35 PKU Related Formulas and Special Food Products Benefits 36 35 Podiatric Benefits 37 35 Pregnancy and Maternity Care Benefits 37 35 Preventive Health Benefits 37 35 Professional (Physician) Benefits 38 36 Prosthetic Appliances Benefits 39 37 Reconstructive Surgery Benefits 39 Rehabilitation 37 Rehabilitative and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 39 38 Skilled Nursing Facility Benefits 40 38 Speech Therapy Benefits (Rehabilitation Rehabilitative and Habilitative Services) 40 38 Transplant Benefits 40 38 Urgent Services Benefits 41 39 Principal Limitations, Exceptions, Exclusions and Reductions 41 40 General Exclusions and Limitations 41 40 Medical Necessity Exclusion 44 43 Table of Contents Page Limitations for Duplicate Coverage 44 43 Exception for Other Coverage 45 Table of Contents Page 43 Claims Review 45 44 Reductions - Third Party Liability 45 44 Coordination of Benefits 46 45 Conditions of Coverage 47 45 Eligibility and Enrollment 47 45 Effective Date of Coverage 48 46 Premiums (Dues) 48 47 Grace Period 48 47 Plan Changes 48 47 Renewal of Group Health Service Contract 49 47 Termination of Benefits (Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 49 Coverage) 47 Extension of Benefits 51 49 Group Continuation Coverage 51 49 General Provisions 54 52 Plan Service Area 54 52 Liability of Subscribers in the Event of Non-Payment by Blue Shield 54 53 Right of Recovery 54 53 No Lifetime Benefit Maximum 55 53 No Annual Dollar Limits on Essential Health Benefits 55 53 Payment of Providers 55 53 Facilities 55 53 Independent Contractors 55 54 Non-Assignability 56 54 Plan Interpretation 56 54 Public Policy Participation Procedure 56 54 Confidentiality of Personal and Health Information 56 55 Access to Information 57 55 Grievance Process 57 55 Medical Services 57 55 Mental Health and Substance Use Disorder Services 58 56 External Independent Medical Review 58 57 Department of Managed Health Care Review 59 Shield Concierge 59 57 Customer Service 57 Definitions 59 58 Notice of the Availability of Language Assistance Services 72 70 Acupuncture and Chiropractic Services Rider 71 Outpatient Prescription Drug Benefits 73 Chiropractic Services 79 Rider 74 Contacting Blue Shield of California 82 Trio HMO Service Area Chart 83 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 98 Summary of Benefits Custom Trio Access+ HMO® Facility Deductible 30-30%/2000 Group Plan HMO Zero Admit 10 City of Delano Effective July 1, 2018 HMO Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services under this Blue Shield of California Benefit planPlan. It is only a summary and it is included as part of the contract for health care coverage, called the Evidence of Coverage (EOC).1 Please read both documents carefully for details. Medical Provider Network: Trio ACO Access+ HMO Network This benefit plan Plan uses a specific network of health care providersHealth Care Providers, called the Trio ACO Access+ HMO provider network. Medical groupsGroups, independent practice associations Independent Practice Associations (IPAs), and physicians Physicians in this network are called participating providersParticipating Providers. You must select a primary care physician Primary Care Physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this planPlan. You can find participating providers Participating Providers in this network at xxxxxxxxxxxx.xxx. Calendar Year Deductibles (CYD)2 Blue Shield of California is an independent member of the Blue Shield Association A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before Blue Shield pays for Covered Services under the Benefit planPlan. Blue Shield pays for some Covered Services before the Calendar Year Deductible is met, as noted in the Benefits chart below. When using a participating provider3 Participating Provider3 Blue Shield of California is an independent member of the Blue Shield Association Calendar year Year medical deductible Deductible Individual coverage $0 2,000 Family coverage $2,000: individual $4,000: Family Calendar Year Out-of-Pocket Maximum4 Family coverage $0: individual $0: family An Out-of-Pocket Maximum is the most a Member will pay for Covered Services each Calendar Year. Any exceptions are listed in the EOC. When using a participating provider3 Participating Provider3 Individual coverage $1,000 3,500 Family coverage $1,0003,500: individual $2,0007,000: family Family No Annual or Lifetime Benefit Maximum Dollar Limit Under this Benefit plan Plan there is no annual or lifetime dollar limit on the total amount Blue Shield will pay for Covered Services in a Member’s lifetimeServices. A47045 A44608 (07/1801/20) 9 Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Preventive Health Services6 Preventive Health Services California Prenatal Screening Program $0 $0 Physician services Primary care office visit Trio+ Access+ specialist care office visit (self-referral) Other specialist care office visit (referred by PCP) Physician home visit Physician or surgeon services in an outpatient facility Physician or surgeon services in an inpatient facility $1030/visit $2045/visit $1030/visit $2530/visit $0 $0 Other professional services Other practitioner office visit Includes nurses, nurse practitioners, physician assistants, and therapists. Teladoc consultation Family planning  Counseling, consulting, and education  Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure.  Tubal ligation  Vasectomy  Infertility services Podiatric services $1030/visit $5/consult $0 $0 $0 $0 50% $1030/visit Pregnancy and maternity care6 Physician office visits: prenatal and postnatal $0 Physician services for pregnancy termination $0 Emergency services and urgent care Emergency room services If admitted to the hospitalHospital, this payment for emergency room services does not apply. Instead, you pay the participating provider Participating Provider payment under Inpatient facility services/ Hospital services and stay. Emergency room physician Physician services $100150/visit $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Urgent care physician center services $1030/visit Inside your primary care physician’s service area, services must be provided or referred by your primary care physician or medical group/IPA. Services outside your primary care physician’s service area are also covered. Services inside your primary care physician’s service area not provided or referred by your primary care physician or medical group/IPA are not covered. Ambulance services This payment is for emergency or authorized transport. $100/transport Outpatient facility services Ambulatory surgery center $0 Surgery Center 20%  Benefits5 Your payment When using a Participating Provider3 CYD2 applies Outpatient department Department of a hospitalHospital: surgery $0 30% Outpatient department Department of a hospitalHospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies  Inpatient facility services Hospital services and stay $0 30% Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.  Special transplant facility inpatient services $0 30%  Physician inpatient services $0   Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services Covered Services that are diagnostic, non- preventive health servicesPreventive Health Services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services Covered Services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test.  Laboratory center $0  Outpatient department Department of a hospital $0  California Prenatal Screening Program Hospital $0 X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center $0  Outpatient department Department of a hospital Hospital $0 Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG.  Office location $0  Outpatient department Department of a hospital Hospital $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Radiological and nuclear imaging services  Outpatient radiology center $0  Outpatient department Department of a hospital Hospital $0 Rehabilitation Rehabilitative and habilitative services Habilitative Services Includes physical therapyPhysical Therapy, occupational therapyOccupational Therapy, respiratory therapyRespiratory Therapy, and speech therapy Speech Therapy services. Office location $1030/visit Outpatient department Department of a hospital Hospital $1030/visit Benefits5 Your payment When using a Participating Provider3 CYD2 applies Durable medical equipment (DME) DME $0 50% Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices $0 Home health care services $30/visit Up to 100 visits per memberMember, per calendar yearCalendar Year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible Deductible period, except hemophilia and home infusion nursing visits. Home health agency services $10/visit Includes home visits by a nurse, home health aideHome Health Aide, medical social worker, physical therapist, speech therapist, or occupational therapist, and medical supplies. Home infusion and home injectable therapy services Home infusion agency services $0 Includes home infusion drugs and medical supplies. Home visits by an infusion nurse $1030/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. Skilled nursing facility Nursing Facility (SNF) services Up to 100 days per memberMember, per benefit periodBenefit Period, except when provided as part of a hospice Hospice program. All days count towards the limit, including days during any applicable deductible Deductible period and days in different SNFs during the calendar yearCalendar Year. Freestanding SNF $0 30% Hospital-based SNF $0 30%   Hospice program services $0 Includes pre-hospice Hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Benefits5 Your payment When using a participating provider3 CYD2 applies Other services and supplies Diabetes care services  Devices, equipment, and supplies $0 20%  Self-management training $1030/visit Dialysis services $0 PKU product formulas and special food products Special Food Products $0 Allergy serum billed separately from an office visit 50% Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder benefits Benefits are provided through Blue Shield's mental health services administrator Mental Health Service Administrator (MHSA). When using a MHSA participating provider3 Participating Provider3 CYD2 applies Outpatient services Office visit, including physician Physician office visit $1030/visit Other outpatient services, including intensive outpatient care, behavioral health treatment electroconvulsive therapy, transcranial magnetic stimulation, Behavioral Health Treatment for pervasive developmental disorder $0 or autism in an office setting, home, or other non-institutional facility $0 setting, and office-based opioid treatment Partial hospitalization program Hospitalization Program $0 Psychological testing Testing $0 Inpatient services Physician inpatient services $0 Hospital services $0 30%  Residential care $0 Care 30%  Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the benefitsBenefits, limitations, and exclusions that apply to coverage under this benefit planPlan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 16 15 How to Use This Health Plan 16 15 Selecting a Primary Care Physician 16 15 Primary Care Physician Relationship 17 16 Role of the Primary Care Physician 17 16 Obstetrical/Gynecological (OB/GYN) Physician Services 17 16 Referral to Specialty Services 17 Role of the Medical Group or IPA 18 16 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Specialist 19 Trio+ Satisfaction 19 18 Mental Health and Substance Use Disorder Services 19 18 Continuity of Care 20 19 Second Medical Opinion 21 19 Urgent Services 21 20 Emergency Services 22 21 Claims for Emergency and Urgent Services 22 21 NurseHelp 24/7 sm 22 21 Life Referrals 24/7 23 21 Blue Shield Online 23 21 Health Education and Health Promotion Services 23 22 Timely Access to Care 23 22 Cost Sharing 23 22 Limitation of Liability 25 23 Out-of-Area Services 25 24 Inter-Plan Arrangements 25 24 BlueCard Program 25 24 Blue Shield Global Core 26 25 Utilization Management 27 26 Principal Benefits and Coverages (Covered Services) 27 26 Allergy Testing and Treatment Benefits 27 26 Ambulance Benefits 28 26 Ambulatory Surgery Center Benefits 28 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 28 26 Diabetes Care Benefits 29 27 Durable Medical Equipment Benefits 29 28 Emergency Room Benefits 30 29 Family Planning and Infertility Benefits 30 29 Home Health Care Benefits 31 29 Home Infusion and Home Injectable Therapy Benefits 31 30 Hospice Program Benefits 32 31 Hospital Benefits (Facility Services) 33 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 34 33 Mental Health and Substance Use Disorder Benefits 35 33 Orthotics Benefits 36 34 Outpatient X-Ray, Pathology and Laboratory 36 35 PKU Related Formulas and Special Food Products Benefits 36 35 Podiatric Benefits 37 35 Pregnancy and Maternity Care Benefits 37 35 Preventive Health Benefits 37 36 Professional (Physician) Benefits 38 36 Prosthetic Appliances Benefits 39 37 Reconstructive Surgery Benefits 39 38 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 39 38 Skilled Nursing Facility Benefits 40 38 Speech Therapy Benefits (Rehabilitation and Habilitative Services) 40 38 Transplant Benefits 40 39 Urgent Services Benefits 41 39 Principal Limitations, Exceptions, Exclusions and Reductions 41 40 General Exclusions and Limitations 41 40 Medical Necessity Exclusion 44 43 Limitations for Duplicate Coverage 44 43 Exception for Other Coverage 45 44 Claims Review 44 Table of Contents Page Claims Review 45 Reductions - Third Party Liability 45 44 Coordination of Benefits 46 45 Conditions of Coverage 47 45 Eligibility and Enrollment 47 45 Effective Date of Coverage 48 46 Premiums (Dues) 48 47 Grace Period 48 47 Plan Changes 48 47 Renewal of Group Health Service Contract 49 47 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 49 47 Extension of Benefits 51 49 Group Continuation Coverage 51 49 General Provisions 54 53 Plan Service Area 54 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 54 53 Right of Recovery 54 53 No Lifetime Benefit Maximum 55 53 No Annual Dollar Limits on Essential Health Benefits 55 53 Payment of Providers 55 53 Facilities 55 54 Independent Contractors 55 54 Non-Assignability 56 54 Plan Interpretation 56 54 Public Policy Participation Procedure 56 54 Confidentiality of Personal and Health Information 56 55 Access to Information 57 55 Grievance Process 57 55 Medical Services 57 55 Mental Health and Substance Use Disorder Services 58 56 External Independent Medical Review 58 57 Department of Managed Health Care Review 59 57 Shield Concierge 59 58 Definitions 59 58 Notice of the Availability of Language Assistance Services 72 69 Outpatient Prescription Drug Benefits 73 70 Acupuncture and Chiropractic Services 79 77 Contacting Blue Shield of California 82 81 Trio HMO Service Area Chart 83 82 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 98 97 Summary of Benefits Custom County of Ventura Trio HMO Zero Admit 10 City County of Delano Ventura Effective July 1December 30, 2018 HMO Benefit Plan This Summary of Benefits shows the amount you will pay for Covered Services covered services under this Blue Shield of California Benefit benefit plan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage (EOC).1 Please read both documents carefully for details. Provider Network: Trio ACO HMO Network This benefit plan uses a specific network of health care providers, called the Trio ACO HMO provider network. Medical groups, independent practice associations (IPAs), and physicians in this network are called participating providers. You must select a primary care physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this plan. You can find participating providers in this network at xxxxxxxxxxxx.xxx. Calendar Year Deductibles (CYD)2 Blue Shield of California is an independent member of the Blue Shield Association A Calendar Year Deductible calendar year deductible (CYD) is the amount a Member member pays each Calendar Year calendar year before Blue Shield pays for Covered Services covered services under the Benefit benefit plan. When using a participating provider3 Calendar year medical deductible Individual coverage $0 Calendar Year Out-of-Pocket Maximum4 Family coverage $0: individual $0: family An Outout-of-Pocket Maximum pocket maximum is the most a Member member will pay for Covered Services covered services each Calendar Yearcalendar year. Any exceptions are listed in the EOC. When using a participating provider3 Individual coverage $1,000 1,500 Family coverage $1,0001,500: individual $2,0003,000: family No Lifetime Benefit Maximum Under this Benefit benefit plan there is no dollar limit on the total amount Blue Shield will pay for Covered Services covered services in a Membermember’s lifetime. A47045 (07/18) 9 Shield Association Benefits5 Your payment When using a participating provider3 CYD2 applies Preventive Health Services6 $0 Physician services Primary care office visit Trio+ specialist care office visit Other specialist care office visit Physician home visit Physician or surgeon services in an outpatient facility Physician or surgeon services in an inpatient facility $1015/visit $20/visit $1015/visit $25/visit $0 $0 Other professional services Other practitioner office visit Includes nurses, nurse practitioners, and therapists. Teladoc consultation Family planning  Counseling, consulting, and education  Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure.  Tubal ligation  Vasectomy  Infertility services Podiatric services $1015/visit $5/consult $0 $0 $0 $0 50% $1015/visit Pregnancy and maternity care6 Physician office visits: prenatal and postnatal $0 Physician services for pregnancy termination $0 Emergency services and urgent care Emergency room services If admitted to the hospital, this payment for emergency room services does not apply. Instead, you pay the participating provider payment under Inpatient facility services/ Hospital services and stay. Emergency room physician services $100/visit $0 Benefits5 Your payment When using a participating provider3 CYD2 applies Ambulance services $100/transport Urgent care physician services $10/visit Inside your primary care physician’s service area, services must be provided or referred by your primary care physician or medical group/IPA. Services outside your primary care physician’s service area are also covered. Services inside your primary care physician’s service area not provided or referred by your primary care physician or medical group/IPA are not covered. Ambulance services $10015/transport visit Outpatient facility services Ambulatory surgery center $0 Outpatient department of a hospital: surgery $0 Outpatient department of a hospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies $50/surgery $50/surgery $0 Inpatient facility services Hospital services and stay $0 Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.  Special transplant facility inpatient services $0  Physician inpatient services $100/admission $100/admission $0 Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services that are diagnostic, non- preventive health services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test.  Laboratory center $0  Outpatient department of a hospital $0  California Prenatal Screening Program $0 X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center $0  Outpatient department of a hospital $0 Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG.  Office location $0  Outpatient department of a hospital $0 $0 $0 $0 $0 Benefits5 Your payment When using a participating provider3 CYD2 applies  Outpatient department of a hospital $0 Radiological and nuclear imaging services  Outpatient radiology center $0 100/test  Outpatient department of a hospital $0 100/test Rehabilitation and habilitative services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location $1015/visit Outpatient department of a hospital $1015/visit Durable medical equipment (DME) DME $0 20% Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices $0 Home health services Up to 100 visits per member, per calendar year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible period, except hemophilia and home infusion nursing visits. Home health agency services $1015/visit Includes home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. Home visits by an infusion nurse $1015/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. Skilled nursing facility (SNF) services Up to 100 days per member, per benefit period, except when provided as part of a hospice program. All days count towards the limit, including days during any applicable deductible period and days in different SNFs during the calendar year. Freestanding SNF $0 Hospital-based SNF $0 Hospice program services $0 Includes pre-hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Benefits5 Your payment When using a participating provider3 CYD2 applies Other services and supplies Diabetes care services  Devices, equipment, and supplies $0 20%  Self-management training $1015/visit Dialysis services $0 PKU product formulas and special food products $0 Allergy serum 50% Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder benefits are provided through Blue Shield's mental health services administrator (MHSA). When using a MHSA participating provider3 CYD2 applies Outpatient services Office visit, including physician office visit $1015/visit Other outpatient services, including intensive outpatient care, behavioral health treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility $0 setting, and office-based opioid treatment Partial hospitalization program $0 Psychological testing $0 Inpatient services $0 $100/admission $100/admission Physician inpatient services $0 Hospital services $0 Residential care $0 Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the benefits, limitations, and exclusions that apply to coverage under this benefit plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time.Notes