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 15 How to Use This Health Plan 15 Selecting a Primary Care Physician 15 Primary Care Physician Relationship 16 Role of the Primary Care Physician 16 Obstetrical/Gynecological (OB/GYN) Physician Services 16 Referral to Specialty Services 16 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Satisfaction 18 Mental Health and Substance Use Disorder Services 18 Continuity of Care 19 Second Medical Opinion 19 Urgent Services 20 Emergency Services 21 Claims for Emergency and Urgent Services 21 NurseHelp 24/7 sm 21 Life Referrals 24/7 21 Blue Shield Online 21 Health Education and Health Promotion Services 22 Timely Access to Care 22 Cost Sharing 22 Limitation of Liability 23 Out-of-Area Services 24 Inter-Plan Arrangements 24 BlueCard Program 24 Blue Shield Global Core 25 Utilization Management 26 Principal Benefits and Coverages (Covered Services) 26 Allergy Testing and Treatment Benefits 26 Ambulance Benefits 26 Ambulatory Surgery Center Benefits 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 Diabetes Care Benefits 27 Durable Medical Equipment Benefits 28 Emergency Room Benefits 29 Family Planning and Infertility Benefits 29 Home Health Care Benefits 29 Home Infusion and Home Injectable Therapy Benefits 30 Hospice Program Benefits 31 Hospital Benefits (Facility Services) 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 33 Mental Health and Substance Use Disorder Benefits 33 Orthotics Benefits 34 Outpatient X-Ray, Pathology and Laboratory 35 PKU Related Formulas and Special Food Products Benefits 35 Podiatric Benefits 35 Pregnancy and Maternity Care Benefits 35 Preventive Health Benefits 36 Professional (Physician) Benefits 36 Prosthetic Appliances Benefits 37 Reconstructive Surgery Benefits 38 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 Skilled Nursing Facility Benefits 38 Speech Therapy Benefits (Rehabilitation and Habilitative Services) 38 Transplant Benefits 39 Urgent Services Benefits 39 Principal Limitations, Exceptions, Exclusions and Reductions 40 General Exclusions and Limitations 40 Medical Necessity Exclusion 43 Limitations for Duplicate Coverage 43 Exception for Other Coverage 44 Claims Review 44 Reductions - Third Party Liability 44 Coordination of Benefits 45 Conditions of Coverage 45 Eligibility and Enrollment 45 Effective Date of Coverage 46 Premiums (Dues) 47 Grace Period 47 Plan Changes 47 Renewal of Group Health Service Contract 47 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 47 Extension of Benefits 49 Group Continuation Coverage 49 General Provisions 53 Plan Service Area 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 53 Right of Recovery 53 No Lifetime Benefit Maximum 53 No Annual Dollar Limits on Essential Health Benefits 53 Payment of Providers 53 Facilities 54 Independent Contractors 54 Non-Assignability 54 Plan Interpretation 54 Public Policy Participation Procedure 54 Confidentiality of Personal and Health Information 55 Access to Information 55 Grievance Process 55 Medical Services 55 Mental Health and Substance Use Disorder Services 56 External Independent Medical Review 57 Department of Managed Health Care Review 57 Shield Concierge 58 Definitions 58 Notice of the Availability of Language Assistance Services 69 Outpatient Prescription Drug Benefits 70 Acupuncture and Chiropractic Services 77 Contacting Blue Shield of California 81 Trio HMO Service Area Chart 82 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 97 Summary of Benefits County of Ventura Trio HMO 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. 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. 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 $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 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. 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 $15/visit $20/visit $15/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 $15/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 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. $15/visit Outpatient facility services Ambulatory surgery center Outpatient department of a hospital: surgery Outpatient department of a hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies $50/surgery $50/surgery $0 Inpatient facility services Hospital services and stay 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  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  Outpatient department of a hospital  California Prenatal Screening Program X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center  Outpatient department of a 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 Benefits5 Your payment When using a participating provider3 CYD2 applies  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 $15/visit Outpatient department of a hospital $15/visit Durable medical equipment (DME) DME 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 $15/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 $15/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 20%  Self-management training $15/visit Dialysis services $0 PKU product formulas and special food products $0 Allergy serum 50% 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 Office visit, including physician office visit $15/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 Hospital services Residential care

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 15 How to Use This Health Plan 15 Selecting a Primary Care Physician 15 Primary Care Physician Relationship 16 Role of the Primary Care Physician 16 Obstetrical/Gynecological (OB/GYN) Physician Services 16 Referral to Specialty Services 16 Role of the Medical Group or IPA 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Satisfaction 18 Mental Health and Substance Use Disorder Services 18 Continuity of Care 19 Second Medical Opinion 19 20 Urgent Services 20 Emergency Services 21 Claims for Emergency and Urgent Services 21 NurseHelp 24/7 sm 21 Life Referrals 24/7 21 22 Blue Shield Online 21 22 Health Education and Health Promotion Services 22 Timely Access to Care 22 Cost Sharing 22 Limitation of Liability 23 24 Out-of-Area Services 24 Inter-Plan Arrangements 24 BlueCard Program 24 Blue Shield Global Core 25 Utilization Management 26 Principal Benefits and Coverages (Covered Services) 26 Allergy Testing and Treatment Benefits 26 Ambulance Benefits 26 27 Ambulatory Surgery Center Benefits 26 27 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 27 Diabetes Care Benefits 27 28 Durable Medical Equipment Benefits 28 Emergency Room Benefits 29 Family Planning and Infertility Benefits 29 Home Health Care Benefits 29 30 Home Infusion and Home Injectable Therapy Benefits 30 Hospice Program Benefits 31 Hospital Benefits (Facility Services) 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 33 Mental Health and Substance Use Disorder Benefits 33 34 Orthotics Benefits 34 35 Outpatient X-Ray, Pathology and Laboratory 35 PKU Related Formulas and Special Food Products Benefits 35 Podiatric Benefits 35 36 Pregnancy and Maternity Care Benefits 35 36 Preventive Health Benefits 36 Professional (Physician) Benefits 36 37 Prosthetic Appliances Benefits 37 38 Reconstructive Surgery Benefits 38 Rehabilitation Rehabilitative and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 Skilled Nursing Facility Benefits 38 39 Speech Therapy Benefits (Rehabilitation Rehabilitative and Habilitative Services) 38 39 Transplant Benefits 39 Urgent Services Benefits 39 40 Principal Limitations, Exceptions, Exclusions and Reductions 40 General Exclusions and Limitations 40 Medical Necessity Exclusion 43 Limitations for Duplicate Coverage 43 Exception for Other Coverage 44 Claims Review 44 Reductions - Third Party Liability 44 Coordination of Benefits 45 Conditions of Coverage 45 46 Eligibility and Enrollment 45 46 Effective Date of Coverage 46 47 Premiums (Dues) 47 Grace Period 47 Plan Changes 47 48 Renewal of Group Health Service Contract 47 48 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 47 48 Extension of Benefits 49 50 Group Continuation Coverage 49 50 General Provisions 53 Plan Service Area 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 53 Right of Recovery 53 54 No Lifetime Benefit Maximum 53 54 No Annual Dollar Limits on Essential Health Benefits 53 54 Payment of Providers 53 54 Facilities 54 Independent Contractors 54 55 Non-Assignability 54 55 Plan Interpretation 54 55 Public Policy Participation Procedure 54 55 Confidentiality of Personal and Health Information 55 56 Access to Information 55 56 Grievance Process 55 56 Medical Services 55 56 Mental Health and Substance Use Disorder Services 56 57 External Independent Medical Review 57 Department of Managed Health Care Review 57 58 Shield Concierge 58 Definitions 58 59 Notice of the Availability of Language Assistance Services 69 70 Outpatient Prescription Drug Benefits 70 Acupuncture and Rider 71 Chiropractic Services 77 Rider 79 Contacting Blue Shield of California 81 83 Trio HMO Service Area Chart 82 84 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 97 Summary of Benefits County of Ventura Trio HMO 99 This Summary of Benefits shows the amount you will pay for covered services Covered Services under this Blue Shield of California benefit planPlan. 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. 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. 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 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 Calendar year Year medical deductible Deductible Individual coverage $0 200 $400: Family Calendar Year Out-of-Pocket Maximum4 $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 Participating Provider3 Under this benefit plan Plan there is no dollar limit on the total amount Blue Shield will pay for covered services Covered Services in a memberMember’s lifetime. Shield Association A47058 (01/19) 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 $1525/visit $2025/visit $1525/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 $1525/visit $5/consult $25/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 center services $25/visit Ambulance services This payment is for emergency or authorized transport. $100/transport Urgent care physician services 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. $15/visit Outpatient facility services Ambulatory surgery center Surgery Center 20%  Outpatient department of a hospitalHospital: surgery 20%  Outpatient department of a hospitalHospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies $50/surgery $50/surgery $0 Inpatient facility services Hospital services and stay 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  Physician inpatient services $100/admission $100/admission $0 20%  20%  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  Outpatient department of a hospital  California Prenatal Screening Program Hospital X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center  Outpatient department of a hospital 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 Benefits5 Your payment When using a participating provider3 CYD2 applies  Outpatient department of a hospital $0 Hospital Radiological and nuclear imaging services  Outpatient radiology center $100/test  Outpatient department of a hospital Hospital $100/test Rehabilitation 0 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 $15/visit Outpatient department of a hospital Hospital $1525/visit $25/visit Durable medical equipment (DME) DME 20% 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 $15/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 $15/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. $25/visit $25/visit 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%  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 20%  Self-management training $15/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 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 Office visit, including physician Physician office visit $1525/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 Physician inpatient services $0 $100/admission $100/admission Physician inpatient services Hospital services 20%  Residential careCare 20%  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 Resignation and Reinstatement 16 Xxxxxx and Reemployment 17 Severance Pay 20 Holidays 20 Election Days 21 Vacations 22 Sick Leave 23 Catastrophic Leave 25 Leaves of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 15 How to Use This Health Plan 15 Selecting a Primary Absence 26 Disability Leave 27 Parental Leave 29 Military Leaves of Absence 29 Attendance in Court 29 Educational Leave 30 Absence Without Leave 30 Hospitalization and Medical Care Physician 15 Primary 31 Dental Care Physician Relationship 16 Role 34 Vision Care 34 Change in Employee Benefit Plans 34 Benefit Booklets 35 Life Insurance 35 Long Term Disability Insurance 35 State Disability Insurance 36 Promotion 36 Career Mobility 37 Part-Time Positions Which Become Full-Time 39 Geographical Displacement 39 Change of the Primary Care Physician 16 Obstetrical/Gynecological (OB/GYN) Physician Services 16 Referral to Specialty Services 16 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Satisfaction 18 Mental Health and Substance Use Disorder Services 18 Continuity of Care 19 Second Medical Opinion 19 Urgent Services 20 Emergency Services 21 Claims Assigned Duties 39 Pay for Emergency and Urgent Services 21 NurseHelp 24/7 sm 21 Life Referrals 24/7 21 Blue Shield Online 21 Health Education and Health Promotion Services 22 Timely Access to Care 22 Cost Sharing 22 Limitation of Liability 23 Work-Out-ofOf-Area Services 24 Inter-Plan Arrangements 24 BlueCard Program 24 Blue Shield Global Core 25 Utilization Management 26 Principal Benefits and Coverages (Covered Services) 26 Allergy Testing and Treatment Benefits 26 Ambulance Benefits 26 Ambulatory Surgery Center Benefits 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 Diabetes Care Benefits 27 Durable Medical Equipment Benefits 28 Emergency Room Benefits 29 Family Planning and Infertility Benefits 29 Home Health Care Benefits 29 Home Infusion and Home Injectable Therapy Benefits 30 Hospice Program Benefits 31 Hospital Benefits (Facility Services) 32 Medical Treatment of the TeethClassification 40 Probationary Period 41 Performance Evaluations 42 Dismissal, Gums, or Jaw Joints and Jaw Bones Benefits 33 Mental Health and Substance Use Disorder Benefits 33 Orthotics Benefits 34 Outpatient X-Ray, Pathology and Laboratory 35 PKU Related Formulas and Special Food Products Benefits 35 Podiatric Benefits 35 Pregnancy and Maternity Care Benefits 35 Preventive Health Benefits 36 Professional (Physician) Benefits 36 Prosthetic Appliances Benefits 37 Reconstructive Surgery Benefits 38 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 Skilled Nursing Facility Benefits 38 Speech Therapy Benefits (Rehabilitation and Habilitative Services) 38 Transplant Benefits 39 Urgent Services Benefits 39 Principal Limitations, Exceptions, Exclusions and Reductions 40 General Exclusions and Limitations 40 Medical Necessity Exclusion 43 Limitations for Duplicate Coverage 43 Exception for Other Coverage 44 Claims Review 44 Reductions - Third Party Liability 44 Coordination of Benefits 45 Conditions of Coverage 45 Eligibility and Enrollment 45 Effective Date of Coverage 46 Premiums (Dues) 47 Grace Period 47 Plan Changes 47 Renewal of Group Health Service Contract 47 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 47 Extension of Benefits 49 Group Continuation Coverage 49 General Provisions 53 Plan Service Area 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 53 Right Punitive Discipline or Demotion for Cause 43 Grievances 43 Loss of Recovery 53 No Lifetime Benefit Maximum 53 No Annual Dollar Limits on Essential Health Compensation 47 Personnel Files 47 Committees 48 Employee Assistance Committee 48 Affirmative Action Advisory Committee 48 Central Safety Committee 48 Deferred Compensation Committee 48 V.D.T 48 Separability of Provisions 49 Past Practices and Existing Memoranda of Understanding 49 Retirement Plans 49 Contracting Out 51 Term of Agreement 51 Benefits 53 Payment of Providers 53 Facilities 54 Independent Contractors 54 Non-Assignability 54 Plan Interpretation 54 Public Policy Participation Procedure 54 Confidentiality of Personal Summary 55 EXHIBIT A Accounting and Health Information 55 Access to Information 55 Grievance Process 55 Medical Administrative Unit 57 EXHIBIT B Appraisal Unit 64 EXHIBIT C Office and Technical Services 55 Mental Health and Substance Use Disorder Services 56 External Independent Medical Review 57 Department of Managed Health Care Review 57 Shield Concierge 58 Definitions 58 Notice of the Availability of Language Assistance Services 69 Outpatient Prescription Drug Benefits 70 Acupuncture and Chiropractic Services 77 Contacting Blue Shield of California 81 Trio HMO Service Area Chart 82 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 97 Summary of Benefits County of Ventura Trio HMO 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. 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. 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 $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 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. 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 $15/visit $20/visit $15/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 $15/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 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. $15/visit Outpatient facility services Ambulatory surgery center Outpatient department of a hospital: surgery Outpatient department of a hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies $50/surgery $50/surgery $0 Inpatient facility services Hospital services and stay 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  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  Outpatient department of a hospital  California Prenatal Screening Unit 66 EXHIBIT D Library Unit 73 EXHIBIT E Engineering Unit 75 EXHIBIT F Career Opportunities Program X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center  Outpatient department of a 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 Benefits5 Your payment When using a participating provider3 CYD2 applies  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 $15/visit Outpatient department of a hospital $15/visit Durable medical equipment (DME) DME 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 $15/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 $15/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 20%  Self-management training $15/visit Dialysis services $0 PKU product formulas and special food products $0 Allergy serum 50% 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 Office visit, including physician office visit $15/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 Hospital services Residential care77

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 15 16 How to Use This Health Plan 15 16 Selecting a Primary Care Physician 15 16 Primary Care Physician Relationship 16 17 Role of the Primary Care Physician 16 17 Obstetrical/Gynecological (OB/GYN) Physician Services 16 17 Referral to Specialty Services 16 17 Role of the Medical Group or IPA 18 Changing Primary Care Physicians or Designated Medical Group or IPA 17 18 Trio+ Specialist 18 19 Trio+ Satisfaction 18 19 Mental Health and Substance Use Disorder Services 18 19 Continuity of Care 19 20 Second Medical Opinion 19 21 Urgent Services 20 21 Emergency Services 21 22 Claims for Emergency and Urgent Services 21 22 NurseHelp 24/7 sm 21 22 Life Referrals 24/7 21 23 Blue Shield Online 21 23 Health Education and Health Promotion Services 22 23 Timely Access to Care 22 23 Cost Sharing 22 23 Limitation of Liability 23 25 Out-of-Area Services 24 25 Inter-Plan Arrangements 24 25 BlueCard Program 24 25 Blue Shield Global Core 25 26 Utilization Management 26 27 Principal Benefits and Coverages (Covered Services) 26 27 Allergy Testing and Treatment Benefits 26 27 Ambulance Benefits 26 28 Ambulatory Surgery Center Benefits 26 28 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 28 Diabetes Care Benefits 27 29 Durable Medical Equipment Benefits 28 29 Emergency Room Benefits 29 30 Family Planning and Infertility Benefits 29 30 Home Health Care Benefits 29 31 Home Infusion and Home Injectable Therapy Benefits 30 31 Hospice Program Benefits 31 32 Hospital Benefits (Facility Services) 32 33 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 33 34 Mental Health and Substance Use Disorder Benefits 33 35 Orthotics Benefits 34 36 Outpatient X-Ray, Pathology and Laboratory 35 36 PKU Related Formulas and Special Food Products Benefits 35 36 Podiatric Benefits 35 37 Pregnancy and Maternity Care Benefits 35 37 Preventive Health Benefits 36 37 Professional (Physician) Benefits 36 38 Prosthetic Appliances Benefits 37 39 Reconstructive Surgery Benefits 38 39 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 39 Skilled Nursing Facility Benefits 38 40 Speech Therapy Benefits (Rehabilitation and Habilitative Services) 38 40 Transplant Benefits 39 40 Urgent Services Benefits 39 41 Principal Limitations, Exceptions, Exclusions and Reductions 40 41 General Exclusions and Limitations 40 41 Medical Necessity Exclusion 43 44 Limitations for Duplicate Coverage 43 44 Exception for Other Coverage 44 45 Claims Review 44 45 Reductions - Third Party Liability 44 45 Coordination of Benefits 45 46 Conditions of Coverage 45 47 Eligibility and Enrollment 45 47 Effective Date of Coverage 46 48 Premiums (Dues) 47 48 Grace Period 47 48 Plan Changes 47 48 Renewal of Group Health Service Contract 47 49 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 47 49 Extension of Benefits 49 51 Group Continuation Coverage 49 51 General Provisions 53 54 Plan Service Area 53 54 Liability of Subscribers in the Event of Non-Payment by Blue Shield 53 54 Right of Recovery 53 54 No Lifetime Benefit Maximum 53 55 No Annual Dollar Limits on Essential Health Benefits 53 55 Payment of Providers 53 55 Facilities 54 55 Independent Contractors 54 55 Non-Assignability 54 56 Plan Interpretation 54 56 Public Policy Participation Procedure 54 56 Confidentiality of Personal and Health Information 55 56 Access to Information 55 57 Grievance Process 55 57 Medical Services 55 57 Mental Health and Substance Use Disorder Services 56 58 External Independent Medical Review 57 58 Department of Managed Health Care Review 57 59 Shield Concierge 58 59 Definitions 58 59 Notice of the Availability of Language Assistance Services 69 72 Outpatient Prescription Drug Benefits 70 Acupuncture and 73 Chiropractic Services 77 79 Contacting Blue Shield of California 81 82 Trio HMO Service Area Chart 82 83 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 97 Summary of Benefits County of Ventura Trio HMO 98 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. 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. 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 $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 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. Shield Association 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 $1510/visit $20/visit $1510/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 $1510/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 $15100/visit 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 $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 Benefits5 Your payment When using a participating provider3 CYD2 applies  Outpatient department of a hospital $0 Radiological and nuclear imaging services  Outpatient radiology center $100/test 0  Outpatient department of a hospital $100/test 0 Rehabilitation and habilitative services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. Office location $1510/visit Outpatient department of a hospital $1510/visit Durable medical equipment (DME) DME 20% $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 $1510/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 $1510/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 20% $0  Self-management training $1510/visit Dialysis services $0 PKU product formulas and special food products $0 Allergy serum 50% 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 Office visit, including physician office visit $1510/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 Physician inpatient services $0 $100/admission $100/admission Physician inpatient services Hospital services $0 Residential carecare $0 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 Access+ HMO Health Plan 15 How to Use This Health Plan 15 Selecting a Primary Care Physician 15 Primary Care Physician Relationship 16 Role of the Primary Care Physician 16 Obstetrical/Gynecological (OB/GYN) Physician Services 16 Referral to Specialty Services 16 Role of the Medical Group or IPA 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Access+ Specialist 18 Trio+ 17 Access+ Satisfaction 18 Mental Health and Substance Use Disorder Services 18 Continuity of Care 19 Second Medical Opinion 19 Urgent Services 20 19 Emergency Services 21 20 Claims for Emergency and Urgent Services 21 NurseHelp 24/7 sm 21 Life Referrals 24/7 21 Blue Shield Online 21 Health Education and Health Promotion Services 22 21 Timely Access to Care 22 21 Cost Sharing 22 Limitation of Liability 23 Out-of-Area Services 24 Inter-Plan Arrangements 24 BlueCard Program 24 Blue Shield Global Core 25 Utilization Management 26 25 Principal Benefits and Coverages (Covered Services) 26 Allergy Testing and Treatment Benefits 26 Ambulance Benefits 26 Ambulatory Surgery Center Benefits 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 Diabetes Care Benefits 27 Durable Medical Equipment Benefits 28 Emergency Room Benefits 29 28 Family Planning and Infertility Benefits 29 Home Health Care Benefits 29 Home Infusion and Home Injectable Therapy Benefits 30 Hospice Program Benefits 31 Hospital Benefits (Facility Services) 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 33 Mental Health and Substance Use Disorder Benefits 33 Orthotics Benefits 34 Outpatient X-Ray, Pathology and Laboratory 35 PKU Related Formulas and Special Food Products Benefits 35 Podiatric Benefits 35 Pregnancy and Maternity Care Benefits 35 Preventive Health Benefits 36 Professional (Physician) Benefits 36 Prosthetic Appliances Benefits 37 Reconstructive Surgery Benefits 38 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 Skilled Nursing Facility Benefits 38 Speech Therapy Benefits (Rehabilitation and Habilitative Services) 38 Transplant Benefits 39 Urgent Services Benefits 39 Principal Limitations, Exceptions, Exclusions and Reductions 40 General Exclusions and Limitations 40 Medical Necessity Exclusion 43 Limitations for Duplicate Coverage 43 Exception for Other Coverage 44 Claims Review 44 Reductions - Third Party Liability 44 Coordination of Benefits 45 Conditions of Coverage 45 Eligibility and Enrollment 45 Effective Date of Coverage 46 Premiums (Dues) 47 Grace Period 47 Plan Changes 47 Renewal of Group Health Service Contract 47 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 47 Extension of Benefits 49 Group Continuation Coverage 49 General Provisions 53 Plan Service Area 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 53 Right of Recovery 53 No Lifetime Benefit Maximum 53 No Annual Dollar Limits on Essential Health Benefits 53 Payment of Providers 53 Facilities 54 Independent Contractors 54 Non-Assignability 54 Plan Interpretation 54 Public Policy Participation Procedure 54 Confidentiality of Personal and Health Information 55 Access to Information 55 Grievance Process 55 Medical Services 55 Mental Health and Substance Use Disorder Services 56 External Independent Medical Review 57 Department of Managed Health Care Review 57 Shield Concierge Customer Service 58 Definitions 58 Notice of the Availability of Language Assistance Services 69 70 Outpatient Prescription Drug Benefits 70 71 Acupuncture and Chiropractic Services 77 78 Contacting Blue Shield of California 81 Trio HMO Service Area Chart 82 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 97 Summary of Benefits County of Ventura Trio HMO 83 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. 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. 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 $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 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. Shield Association A16203 (12/18) 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 $1535/visit $2040/visit $1535/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 $1535/visit $5/consult $0 $0 $0 $0 50% $35/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 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. $1535/visit Outpatient facility services Ambulatory surgery center Outpatient department of a hospital: surgery Outpatient department of a hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies $50250/surgery $50250/surgery $0 Inpatient facility services Hospital services and stay 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  • Physician inpatient services $100500/admission $100500/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  • Outpatient department of a hospital  • California Prenatal Screening Program X-ray and imaging services Includes diagnostic mammography.  • Outpatient radiology center  • Outpatient department of a 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 $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 $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 $1535/visit Outpatient department of a hospital $1535/visit Durable medical equipment (DME) DME 2050% 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 $1535/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 $1535/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 20%  • Self-management training $1535/visit Dialysis services $0 PKU product formulas and special food products $0 Allergy serum 50% 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 $1535/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 $0 $100/admission $100/admission Physician inpatient services $0 Hospital services $500/admission Residential carecare $500/admission

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 15 How to Use This Health Plan 15 Selecting a Primary Care Physician 15 Primary Care Physician Relationship 16 Role of the Primary Care Physician 16 Obstetrical/Gynecological (OB/GYN) Physician Services 16 Referral to Specialty Services 16 Role of the Medical Group or IPA 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Satisfaction 18 Mental Health and Substance Use Disorder Services 18 Continuity of Care 19 Second Medical Opinion 19 20 Urgent Services 20 Emergency Services 21 Claims for Emergency and Urgent Services 21 NurseHelp 24/7 sm 21 Life Referrals 24/7 21 22 Blue Shield Online 21 22 Health Education and Health Promotion Services 22 Timely Access to Care 22 Cost Sharing 22 Limitation of Liability 23 24 Out-of-Area Services 24 Inter-Plan Arrangements 24 BlueCard Program 24 Blue Shield Global Core 25 Utilization Management 26 Principal Benefits and Coverages (Covered Services) 26 Allergy Testing and Treatment Benefits 26 Ambulance Benefits 26 Ambulatory Surgery Center Benefits 26 27 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 27 Diabetes Care Benefits 27 28 Durable Medical Equipment Benefits 28 Emergency Room Benefits 29 Family Planning and Infertility Benefits 29 Home Health Care Benefits 29 30 Home Infusion and Home Injectable Therapy Benefits 30 Hospice Program Benefits 31 Hospital Benefits (Facility Services) 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 33 Mental Health and Substance Use Disorder Benefits 33 34 Orthotics Benefits 34 35 Outpatient X-Ray, Pathology and Laboratory 35 PKU Related Formulas and Special Food Products Benefits 35 Podiatric Benefits 35 Pregnancy and Maternity Care Benefits 35 36 Preventive Health Benefits 36 Professional (Physician) Benefits 36 Prosthetic Appliances Benefits 37 38 Reconstructive Surgery Benefits 38 Rehabilitation Rehabilitative and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 Skilled Nursing Facility Benefits 38 Speech Therapy Benefits (Rehabilitation Rehabilitative and Habilitative Services) 38 39 Transplant Benefits 39 Urgent Services Benefits 39 Principal Limitations, Exceptions, Exclusions and Reductions 40 General Exclusions and Limitations 40 Medical Necessity Exclusion 43 Limitations for Duplicate Coverage 43 Exception for Other Coverage 44 Claims Review 44 Reductions - Third Party Liability 44 Coordination of Benefits 45 Conditions of Coverage 45 46 Eligibility and Enrollment 45 46 Effective Date of Coverage 46 47 Premiums (Dues) 47 Grace Period 47 Plan Changes 47 Renewal of Group Health Service Contract 47 Termination of Benefits (Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 47 Coverage) 48 Extension of Benefits 49 50 Group Continuation Coverage 49 50 General Provisions 53 Plan Service Area 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 53 Right of Recovery 53 No Lifetime Benefit Maximum 53 54 No Annual Dollar Limits on Essential Health Benefits 53 54 Payment of Providers 53 54 Facilities 54 Independent Contractors 54 Non-Assignability 54 Plan Interpretation 54 55 Public Policy Participation Procedure 54 55 Confidentiality of Personal and Health Information 55 Access to Information 55 Grievance Process 55 56 Medical Services 55 56 Mental Health and Substance Use Disorder Services 56 External Independent Medical Review 57 Department of Managed Health Care Review 57 58 Shield Concierge 58 Definitions 58 Notice of the Availability of Language Assistance Services 69 Outpatient Prescription Drug Benefits 70 Acupuncture and Chiropractic Services 77 Rider 71 Outpatient Prescription Drug Rider 74 Contacting Blue Shield of California 81 83 Trio HMO Service Area Chart 82 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 97 Summary of Benefits County of Ventura Trio HMO 84 This Summary of Benefits shows the amount you will pay for covered services 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. 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. 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 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 $4,000: Family Calendar Year Out-of-Pocket Maximum4 $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 Participating Provider3 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 lifetimeCovered Services. Shield Association A47059 (01/20) 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 $1530/visit $2030/visit $1530/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 $1530/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 Urgent care center services $30/visit Ambulance services This payment is for emergency or authorized transport. $100/transport Outpatient facility services Ambulatory Surgery Center 20%  Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Ambulance services $100/transport Urgent care physician services 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. $15/visit Outpatient facility services Ambulatory surgery center Outpatient department Department of a hospitalHospital: surgery 30% Outpatient department Department of a hospitalHospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies $50/surgery $50/surgery $0  Inpatient facility services Hospital services and stay 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 30%  Physician inpatient services $100/admission $100/admission $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  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 Benefits5 Your payment When using a participating provider3 CYD2 applies  Outpatient department Department of a hospital Hospital $0 Radiological and nuclear imaging services  Outpatient radiology center $100/test 0  Outpatient department Department of a hospital Hospital $100/test Rehabilitation 0 Rehabilitative and habilitative services Habilitative Services Includes physical therapyPhysical Therapy, occupational therapyOccupational Therapy, respiratory therapyRespiratory Therapy, and speech therapy Speech Therapy services. Office location $1530/visit Outpatient department Department of a hospital Hospital $1530/visit Benefits5 Your payment When using a Participating Provider3 CYD2 applies Durable medical equipment (DME) DME 2050% 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 $15/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 $1530/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 20%  Self-management training $1530/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 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 Office visit, including physician Physician office visit $1530/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 Physician inpatient services $0 $100/admission $100/admission Physician inpatient services Hospital services 30%  Residential careCare 30%  The Evidence of Coverage (EOC) describes the Benefits, limitations, and exclusions that apply to coverage under this 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 Access+ HMO Health Plan 15 How to Use This Health Plan 15 Selecting a Primary Care Physician 15 Primary Care Physician Relationship 16 Role of the Primary Care Physician 16 Obstetrical/Gynecological (OB/GYN) Physician Services 16 Referral to Specialty Services 16 Role of the Medical Group or IPA 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Access+ Specialist 18 Trio+ 17 Access+ Satisfaction 18 Mental Health and Substance Use Disorder Services 18 Continuity of Care 19 Second Medical Opinion 19 Urgent Services 20 19 Emergency Services 21 20 Claims for Emergency and Urgent Services 21 NurseHelp 24/7 sm 21 Life Referrals 24/7 21 Blue Shield Online 21 Health Education and Health Promotion Services 22 21 Timely Access to Care 22 21 Cost Sharing 22 Limitation of Liability 23 Out-of-Area Services 24 Inter-Plan Arrangements 24 BlueCard Program 24 Blue Shield Global Core 25 Utilization Management 26 25 Principal Benefits and Coverages (Covered Services) 26 25 Allergy Testing and Treatment Benefits 26 Ambulance Benefits 26 Ambulatory Surgery Center Benefits 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 Diabetes Care Benefits 27 Durable Medical Equipment Benefits 28 Emergency Room Benefits 29 28 Family Planning and Infertility Benefits 29 Home Health Care Benefits 29 Home Infusion and Home Injectable Therapy Benefits 30 Hospice Program Benefits 31 Hospital Benefits (Facility Services) 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 33 Mental Health and Substance Use Disorder Benefits 33 Orthotics Benefits 34 Outpatient X-Ray, Pathology and Laboratory 35 PKU Related Formulas and Special Food Products Benefits 35 Podiatric Benefits 35 Pregnancy and Maternity Care Benefits 35 Preventive Health Benefits 36 35 Professional (Physician) Benefits 36 Prosthetic Appliances Benefits 37 Reconstructive Surgery Benefits 38 Rehabilitation 37 Rehabilitative and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 Skilled Nursing Facility Benefits 38 Speech Therapy Benefits (Rehabilitation Rehabilitative and Habilitative Services) 38 Transplant Benefits 39 38 Urgent Services Benefits 39 Principal Limitations, Exceptions, Exclusions and Reductions 40 General Exclusions and Limitations 40 Medical Necessity Exclusion 43 Limitations for Duplicate Coverage 43 Exception for Other Coverage 44 43 Claims Review 44 Reductions - Third Party Liability 44 Coordination of Benefits 45 Conditions of Coverage 45 Eligibility and Enrollment 45 Effective Date of Coverage 46 Premiums (Dues) 47 Grace Period 47 Plan Changes 47 Renewal of Group Health Service Contract 47 Termination of Benefits (Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact Coverage) 47 Extension of Benefits 49 Group Continuation Coverage 49 General Provisions 53 52 Plan Service Area 53 52 Liability of Subscribers in the Event of Non-Payment by Blue Shield 53 Right of Recovery 53 No Lifetime Benefit Maximum 53 No Annual Dollar Limits on Essential Health Benefits 53 Payment of Providers 53 Facilities 54 53 Independent Contractors 54 Non-Assignability 54 Plan Interpretation 54 Public Policy Participation Procedure 54 Confidentiality of Personal and Health Information 55 Access to Information 55 Grievance Process 55 Medical Services 55 Mental Health and Substance Use Disorder Services 56 External Independent Medical Review 57 Department of Managed Health Care Review 57 Shield Concierge 58 Customer Service 57 Definitions 58 Notice of the Availability of Language Assistance Services 69 Outpatient Prescription Drug Benefits 70 Acupuncture and Chiropractic Services 77 Rider 71 Outpatient Prescription Drug Rider 74 Contacting Blue Shield of California 81 Trio HMO Service Area Chart 82 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 97 Summary of Benefits County of Ventura Trio HMO 83 Access+ HMO® Facility Deductible 30-30%/2000 This Summary of Benefits shows the amount you will pay for covered services 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. 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. 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 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 $4,000: Family Calendar Year Out-of-Pocket Maximum4 $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 Participating Provider3 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 lifetimeCovered Services. Shield Association A44608 (01/20) 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 $1530/visit $2045/visit $1530/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 $1530/visit $5/consult $0 $0 $0 $0 $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 Urgent care center services $30/visit Ambulance services This payment is for emergency or authorized transport. $100/transport Outpatient facility services Ambulatory Surgery Center 20% ✔ Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies Ambulance services $100/transport Urgent care physician services 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. $15/visit Outpatient facility services Ambulatory surgery center Outpatient department Department of a hospitalHospital: surgery Outpatient department Department of a hospitalHospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies $50/surgery $50/surgery 30% $0 ✔ Inpatient facility services Hospital services and stay 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  • Physician inpatient services $100/admission $100/admission 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  • Outpatient department Department of a hospital  California Prenatal Screening Program Hospital X-ray and imaging services Includes diagnostic mammography.  • Outpatient radiology center  • Outpatient department Department of a hospital 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 of a Hospital $30/visit $30/visit Benefits5 Your payment When using a participating provider3 Participating Provider3 CYD2 applies  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 $15/visit Outpatient department of a hospital $15/visit Durable medical equipment (DME) DME 20% 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 $15/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 $15/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 20%  • Self-management training $15/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 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 Office visit, including physician Physician office visit $1530/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 Physician inpatient services $0 $100/admission $100/admission Physician inpatient services Hospital services 30% ✔ Residential careCare 30% ✔ The Evidence of Coverage (EOC) describes the Benefits, limitations, and exclusions that apply to coverage under this 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 Xxxxxx and Reemployment 17 Severance Pay 20 Holidays 20 Election Days 21 Vacations 22 Sick Leave. 23 Catastrophic Leave 25 Leaves of Absence 26 Disability Leave 27 Parental Leave. 29 Military Leaves of Absence 29 Attendance in Court 30 Educational Leave. 30 Absence Without Leave 30 Hospitalization and Medical Care. 31 Dental Care 34 Vision Care 34 Change in Employee Benefit Plans 34 Benefit Booklets 35 Life Insurance 35 Long Term Disability Insurance 35 State Disability Insurance 35 Promotion. 36 Career Mobility 37 Part-Time Positions Which Become Full-Time 39 Geographical Displacement 39 Change of Assigned Duties 39 Pay for Work-Out-Of-Classification 40 Probationary Period 41 Performance Evaluations 42 Dismissal, Non-Punitive Discipline or Demotion for Cause 43 Grievances 43 Loss of Compensation 46 Personnel Files 47 Committees 48 Employee Assistance Committee 48 Affirmative Action Advisory Committee 48 Central Safety Committee 48 Deferred Compensation Committee 48 V.D.T. 48 Separability of Provisions 49 Past Practices and Existing Memoranda of Understanding 49 Retirement Plans 49 Contracting Out. 50 Term of Agreement 50 Benefits 9 Introduction Summary. 54 EXHIBIT A Accounting and Administrative Unit 56 EXHIBIT B Appraisal Unit 62 EXHIBIT C Office and Technical Services Unit 64 EXHIBIT D Library Unit 68 EXHIBIT E Engineering Unit 70 EXHIBIT F Career Opportunities Program 72 Local 521, Service Employees International Union, and representatives of the County of San Mateo have met and conferred in good faith regarding wages, hours and other terms and conditions of employment of workers in the representation units listed in Section 1, have exchanged freely information, opinions and proposals and have endeavored to reach agreement on all matters relating to the Blue Shield Trio HMO Health Plan 15 How to Use This Health Plan 15 Selecting a Primary Care Physician 15 Primary Care Physician Relationship 16 Role employment conditions and employer-employee relations of the Primary Care Physician 16 Obstetrical/Gynecological (OB/GYN) Physician Services 16 Referral to Specialty Services 16 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Satisfaction 18 Mental Health and Substance Use Disorder Services 18 Continuity of Care 19 Second Medical Opinion 19 Urgent Services 20 Emergency Services 21 Claims for Emergency and Urgent Services 21 NurseHelp 24/7 sm 21 Life Referrals 24/7 21 Blue Shield Online 21 Health Education and Health Promotion Services 22 Timely Access to Care 22 Cost Sharing 22 Limitation of Liability 23 Out-of-Area Services 24 Inter-Plan Arrangements 24 BlueCard Program 24 Blue Shield Global Core 25 Utilization Management 26 Principal Benefits and Coverages (Covered Services) 26 Allergy Testing and Treatment Benefits 26 Ambulance Benefits 26 Ambulatory Surgery Center Benefits 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 Diabetes Care Benefits 27 Durable Medical Equipment Benefits 28 Emergency Room Benefits 29 Family Planning and Infertility Benefits 29 Home Health Care Benefits 29 Home Infusion and Home Injectable Therapy Benefits 30 Hospice Program Benefits 31 Hospital Benefits (Facility Services) 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 33 Mental Health and Substance Use Disorder Benefits 33 Orthotics Benefits 34 Outpatient X-Ray, Pathology and Laboratory 35 PKU Related Formulas and Special Food Products Benefits 35 Podiatric Benefits 35 Pregnancy and Maternity Care Benefits 35 Preventive Health Benefits 36 Professional (Physician) Benefits 36 Prosthetic Appliances Benefits 37 Reconstructive Surgery Benefits 38 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 Skilled Nursing Facility Benefits 38 Speech Therapy Benefits (Rehabilitation and Habilitative Services) 38 Transplant Benefits 39 Urgent Services Benefits 39 Principal Limitations, Exceptions, Exclusions and Reductions 40 General Exclusions and Limitations 40 Medical Necessity Exclusion 43 Limitations for Duplicate Coverage 43 Exception for Other Coverage 44 Claims Review 44 Reductions - Third Party Liability 44 Coordination of Benefits 45 Conditions of Coverage 45 Eligibility and Enrollment 45 Effective Date of Coverage 46 Premiums (Dues) 47 Grace Period 47 Plan Changes 47 Renewal of Group Health Service Contract 47 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 47 Extension of Benefits 49 Group Continuation Coverage 49 General Provisions 53 Plan Service Area 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 53 Right of Recovery 53 No Lifetime Benefit Maximum 53 No Annual Dollar Limits on Essential Health Benefits 53 Payment of Providers 53 Facilities 54 Independent Contractors 54 Non-Assignability 54 Plan Interpretation 54 Public Policy Participation Procedure 54 Confidentiality of Personal and Health Information 55 Access to Information 55 Grievance Process 55 Medical Services 55 Mental Health and Substance Use Disorder Services 56 External Independent Medical Review 57 Department of Managed Health Care Review 57 Shield Concierge 58 Definitions 58 Notice of the Availability of Language Assistance Services 69 Outpatient Prescription Drug Benefits 70 Acupuncture and Chiropractic Services 77 Contacting Blue Shield of California 81 Trio HMO Service Area Chart 82 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 97 Summary of Benefits County of Ventura Trio HMO 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 detailssuch employees. This benefit plan uses a specific network Memorandum of health care providers, called the Trio ACO HMO provider network. Medical groups, independent practice associations Understanding (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. A calendar year deductible (CYDMOU) 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 $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 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. 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 $15/visit $20/visit $15/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 $15/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 entered into pursuant to the hospital, this payment for emergency room services does not apply. Instead, you pay Xxxxxx-Xxxxxx-Xxxxx Act (Government Code Sections 3500-3510) and has been jointly prepared by 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 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. $15/visit Outpatient facility services Ambulatory surgery center Outpatient department of a hospital: surgery Outpatient department of a hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies $50/surgery $50/surgery $0 Inpatient facility services Hospital services and stay 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  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  Outpatient department of a hospital  California Prenatal Screening Program X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center  Outpatient department of a 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 Benefits5 Your payment When using a participating provider3 CYD2 applies  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 $15/visit Outpatient department of a hospital $15/visit Durable medical equipment (DME) DME 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 $15/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 $15/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 20%  Self-management training $15/visit Dialysis services $0 PKU product formulas and special food products $0 Allergy serum 50% 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 Office visit, including physician office visit $15/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 Hospital services Residential careparties.

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio HMO Health Plan 15 How to Use This Health Plan 15 Selecting a Primary Care Physician 15 Primary Care Physician Relationship 16 Role of the Primary Care Physician 16 Obstetrical/Gynecological (OB/GYN) Physician Services 16 Referral to Specialty Services 16 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Specialist 18 Trio+ Satisfaction 18 Mental Health 8 Unit Member Observation, Evaluation, and Substance Use Disorder Services 18 Continuity of Care Records -Non-Tenured Unit Member Procedures for Evaluation 19 Second Medical Opinion 19 Urgent Services 20 Emergency Services 21 Claims for Emergency and Urgent Services 21 NurseHelp 24/7 sm 21 Life Referrals 24/7 21 Blue Shield Online 21 Health Education and Health Promotion Services 22 Timely Access to Care 22 Cost Sharing 22 Limitation of Liability 23 Out-of-Area Services 24 Inter-Plan Arrangements 24 BlueCard Program 24 Blue Shield Global Core 25 Utilization Management 26 Principal Benefits and Coverages (Covered Services) 26 Allergy Testing and Treatment Benefits 26 Ambulance Benefits 26 Ambulatory Surgery Center Benefits 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 Diabetes Care Benefits 27 Durable Medical Equipment Benefits 28 Emergency Room Benefits 29 Family Planning and Infertility Benefits 29 Home Health Care Benefits 29 Home Infusion and Home Injectable Therapy Benefits 30 Hospice Program Benefits 31 Hospital Benefits (Facility Services) 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 33 Mental Health and Substance Use Disorder Benefits 33 Orthotics Benefits 34 Outpatient X-Ray, Pathology and Laboratory 35 PKU Related Formulas and Special Food Products Benefits 35 Podiatric Benefits 35 Pregnancy and Maternity Care Benefits 35 Preventive Health Benefits 36 Professional (Physician) Benefits 36 Prosthetic Appliances Benefits 37 Reconstructive Surgery Benefits 38 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 Skilled Nursing Facility Benefits 38 Speech Therapy Benefits (Rehabilitation and Habilitative Services) 38 Transplant Benefits 39 Urgent Services Benefits 39 Principal Limitations, Exceptions, Exclusions and Reductions 40 General Exclusions and Limitations 40 Medical Necessity Exclusion 43 Limitations for Duplicate Coverage 43 Exception for Other Coverage 44 Claims Review 44 Reductions - Third Party Liability 44 Coordination of Benefits 45 Conditions of Coverage 45 Eligibility and Enrollment 45 Effective Date of Coverage 46 Premiums (Dues) 47 Grace Period 47 Plan Changes 47 Renewal of Group Health Service Contract 47 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 47 Extension of Benefits 49 Group Continuation Coverage 49 General Provisions 53 Plan Service Area 53 Liability of Subscribers in the Event -Protection of Non-Payment by Blue Shield 53 Right Tenured Unit Members 19 -Unit Members with Tenure 20 -Unit Member Observation and Evaluation 20 -Unit Member Records 20 -Unit Member Response 20 -Reprimands 20 -Year End Evaluation 20 -Instrument Design 20 9 Miscellaneous 21 -Copies of Recovery 53 No Lifetime Board Agenda 21 -Reprisals Prohibited 21 -Tax Sheltered Annuity 21 -Credit Union 21 -Dues Deduction 21 -Agency Fee 21 -Rehired Full Time Substitutes 22 -Children of Teachers 22 10 NYSUT Benefit Maximum 53 No Annual Dollar Limits on Essential Trust & VOTE/COPE 22 -Vote-Cope Deductions 22 11 Salary and Benefits 22 -Salary Schedules 22 -Teaching Assistant Salaries 23 -Part-time Unit Members 23 -Career Increments 24 -Graduate Hours 24 -Masters Degree Stipend 25 -Standardized Hourly Rates 25 -Health Insurance 26 -Payment in Lieu of Health Insurance 27 -Sick Leave Conversion for Retirement 27 -Dental Policy 28 -Medical Exams 28 -Life Insurance 28 -Paycheck Options 29 -Section 125 Flexible Benefits 53 Payment Plan 29 -Long-Term Substitute Unit Members 29 ARTICLE PAGE 12 Association Activities 30 -Communications 30 -Special Meetings 30 -Conducting Business 30 -Board of Providers 53 Facilities 54 Independent Contractors 54 Education Meetings 30 -Delegate Leave Time 30 -Release Time 30 -Association President 31 13 Work Year 31 -Length of Work Year 31 -Orientation Day for New Unit Members 31 -School Calendar 31 -Rescheduled Vacation Days 31 -Student Free Work Day 31 14 Negotiations Procedure and Duration 31 -Negotiations Procedure 31 -Duration of Agreement 32 Appendix B-1 Non-Assignability 54 Plan Interpretation 54 Athletic Extra Curricular 33 Appendix B-2 Athletic Extra Curricular 34 Appendix B-3 Teacher Salary Schedule 36 Appendix B-4 TA Salary Schedule 37 Appendix B-5 Standardized Rates 38 Appendix C Sick Bank Application Form 40 CAP MOA 41 This Agreement is made pursuant to the Public Policy Participation Procedure 54 Confidentiality of Personal Employees' Fair Employment Act, and Health Information 55 Access is entered into by and between THE XXXXXX CENTRAL SCHOOL TEACHERS' ASSOCIATION (hereinafter referred to Information 55 Grievance Process 55 Medical Services 55 Mental Health and Substance Use Disorder Services 56 External Independent Medical Review 57 Department of Managed Health Care Review 57 Shield Concierge 58 Definitions 58 Notice of as the Availability of Language Assistance Services 69 Outpatient Prescription Drug Benefits 70 Acupuncture and Chiropractic Services 77 Contacting Blue Shield of California 81 Trio HMO Service Area Chart 82 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 97 Summary of Benefits County of Ventura Trio HMO 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. This benefit plan uses a specific network of health care providers, called the Trio ACO HMO provider network. Medical groups, independent practice associations (IPAsAssociation), and physicians in this network are called participating providers. You must select a primary care physician from this network the XXXXXX CENTRAL SCHOOL SUPERINTENDENT (hereinafter referred 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. A calendar year deductible (CYD) is as 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 $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 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. 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 $15/visit $20/visit $15/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 (IUDSuperintendent.), implantable contraceptive, and related procedure.  Tubal ligation  Vasectomy  Infertility services Podiatric services $15/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 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. $15/visit Outpatient facility services Ambulatory surgery center Outpatient department of a hospital: surgery Outpatient department of a hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies $50/surgery $50/surgery $0 Inpatient facility services Hospital services and stay 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  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  Outpatient department of a hospital  California Prenatal Screening Program X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center  Outpatient department of a 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 Benefits5 Your payment When using a participating provider3 CYD2 applies  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 $15/visit Outpatient department of a hospital $15/visit Durable medical equipment (DME) DME 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 $15/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 $15/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 20%  Self-management training $15/visit Dialysis services $0 PKU product formulas and special food products $0 Allergy serum 50% 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 Office visit, including physician office visit $15/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 Hospital services Residential care

TABLE OF CONTENTS PAGE. Summary of Benefits 9 Introduction to the Blue Shield Trio Access+ HMO Health Plan 15 How to Use This Health Plan 15 Selecting a Primary Care Physician 15 Primary Care Physician Relationship 16 Role of the Primary Care Physician 16 Obstetrical/Gynecological (OB/GYN) Physician Services 16 Referral to Specialty Services 16 Role of the Medical Group or IPA 17 Changing Primary Care Physicians or Designated Medical Group or IPA 17 Trio+ Access+ Specialist 18 Trio+ 17 Access+ Satisfaction 18 Mental Health and Substance Use Disorder Services 18 Continuity of Care 19 Second Medical Opinion 19 Urgent Services 20 19 Emergency Services 21 20 Claims for Emergency and Urgent Services 21 NurseHelp 24/7 sm 21 Life Referrals 24/7 21 Blue Shield Online 21 Health Education and Health Promotion Services 22 21 Timely Access to Care 22 21 Cost Sharing 22 Limitation of Liability 23 Out-of-Area Services 24 Inter-Plan Arrangements 24 BlueCard Program 24 Blue Shield Global Core 25 Utilization Management 26 25 Principal Benefits and Coverages (Covered Services) 26 Allergy Testing and Treatment Benefits 26 Ambulance Benefits 26 Ambulatory Surgery Center Benefits 26 Clinical Trial for Treatment of Cancer or Life-Threatening Conditions Benefits 26 Diabetes Care Benefits 27 Durable Medical Equipment Benefits 28 Emergency Room Benefits 29 28 Family Planning and Infertility Benefits 29 Home Health Care Benefits 29 Home Infusion and Home Injectable Therapy Benefits 30 Hospice Program Benefits 31 Hospital Benefits (Facility Services) 32 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits 33 Mental Health and Substance Use Disorder Benefits 33 Orthotics Benefits 34 Outpatient X-Ray, Pathology and Laboratory 35 PKU Related Formulas and Special Food Products Benefits 35 Podiatric Benefits 35 Pregnancy and Maternity Care Benefits 35 Preventive Health Benefits 36 Professional (Physician) Benefits 36 Prosthetic Appliances Benefits 37 Reconstructive Surgery Benefits 38 Rehabilitation Rehabilitative and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) 38 Skilled Nursing Facility Benefits 38 Speech Therapy Benefits (Rehabilitation Rehabilitative and Habilitative Services) 38 Transplant Benefits 39 Urgent Services Benefits 39 Principal Limitations, Exceptions, Exclusions and Reductions 40 General Exclusions and Limitations 40 Medical Necessity Exclusion 43 Limitations for Duplicate Coverage 43 Exception for Other Coverage 44 Claims Review 44 Reductions - Third Party Liability 44 Coordination of Benefits 45 Conditions of Coverage 45 46 Eligibility and Enrollment 45 46 Effective Date of Coverage 46 Premiums (Dues) 47 Grace Period 47 Plan Changes 47 Renewal of Group Health Service Contract 47 Cancellation and Rescission for Termination for Fraud and Intentional Misrepresentations of Material Fact 47 48 Extension of Benefits 49 Group Continuation Coverage 49 50 General Provisions 53 Plan Service Area 53 Liability of Subscribers in the Event of Non-Payment by Blue Shield 53 Right of Recovery 53 No Lifetime Benefit Maximum 53 No Annual Dollar Limits on Essential Health Benefits 53 Payment of Providers 53 Facilities 54 Independent Contractors 54 Non-Assignability 54 Plan Interpretation 54 Public Policy Participation Procedure 54 Confidentiality of Personal and Health Information 55 Access to Information 55 Grievance Process 55 56 Medical Services 55 56 Mental Health and Substance Use Disorder Services 56 External Independent Medical Review 57 Department of Managed Health Care Review 57 Shield Concierge Customer Service 58 Definitions 58 Notice of the Availability of Language Assistance Services 69 70 Outpatient Prescription Drug Benefits 70 Acupuncture and Rider 71 Chiropractic Services 77 Rider 79 Contacting Blue Shield of California 81 Trio HMO Service Area Chart 82 83 Notice Informing Individuals about Nondiscrimination and Accessibility Requirements 97 Summary of Benefits County of Ventura Trio HMO 85 This Summary of Benefits shows the amount you will pay for covered services Covered Services under this Blue Shield of California benefit planPlan. 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. 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. 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 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 Calendar year Year medical deductible Deductible Individual coverage $0 200 $400: Family Calendar Year Out-of-Pocket Maximum4 $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 Participating Provider3 Under this benefit plan Plan there is no dollar limit on the total amount Blue Shield will pay for covered services Covered Services in a memberMember’s lifetime. Shield Association A44607 (01/19) 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 $1525/visit $2040/visit $1525/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 $1525/visit $5/consult $25/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 center services $25/visit Ambulance services This payment is for emergency or authorized transport. $100/transport Urgent care physician services 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. $15/visit Outpatient facility services Ambulatory surgery center Surgery Center 20%  Outpatient department of a hospitalHospital: surgery 20%  Outpatient department of a hospitalHospital: treatment of illness or injury, $0 radiation therapy, chemotherapy, and necessary supplies $50/surgery $50/surgery $0 Inpatient facility services Hospital services and stay 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  Physician inpatient services $100/admission $100/admission $0 20%  20%  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  Outpatient department of a hospital  California Prenatal Screening Program Hospital X-ray and imaging services Includes diagnostic mammography.  Outpatient radiology center  Outpatient department of a hospital 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 Benefits5 Your payment When using a participating provider3 CYD2 applies  Outpatient department of a hospital $0 Hospital Radiological and nuclear imaging services  Outpatient radiology center $100/test  Outpatient department of a hospital Hospital $100/test Rehabilitation 0 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 $15/visit Outpatient department of a hospital Hospital $1525/visit $25/visit Durable medical equipment (DME) DME 20% 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 $15/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 $15/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. $25/visit $25/visit 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%  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 20%  Self-management training $15/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 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 Office visit, including physician Physician office visit $1525/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 Physician inpatient services $0 $100/admission $100/admission Physician inpatient services Hospital services 20%  Residential careCare 20% 