Page 8 - Surfline Benefits Guide 2017

Medical

Blue Shield | Platinum HMO Medical Plan
With the Blue Shield Health Maintenance Organization Access+ (HMO) plan, you must choose a primary care physician (PCP) within the provider
network. All of your care must be directed through your PCP. You will receive benefits only if you use the doctors, clinics, and hospitals that
belong to the medical group in which you are enrolled, except in the case of an emergency. This plan allows you to receive specialist referrals
from your PCP, or you may self-refer to Access+ specialists within your PCP’s medical group for a higher copay.

Blue Shield | Silver PPO HSA Medical Plan
With the Blue Shield Preferred Provider Organization (PPO) Health Savings Account (HSA) plan through Blue Shield, you can pay for qualified
healthcare expenses now and grow your savings for future healthcare needs. This plan combines a High Deductible Health Plan (HDHP) with
the ability to open a special, tax-qualified savings account (HSA). You can contribute tax-free money to your HSA up to IRS maximums. The
money in your account is yours to pay for current healthcare expenses - or you can save toward future healthcare expenses. Because it’s a PPO
medical plan, you have the freedom to choose your doctor without the requirement of selecting a PCP and you may self-refer to specialists.
You may use a network provider whose negotiated rates provide richer levels of benefits with claim forms filed by the providers. You may
also obtain services using a non-network provider; however, you will be responsible for the difference between the covered amount and the
actual charges and you may be responsible for filing claims. For additional information on how the HSA plan works, see page 10 of this guide.

Blue Shield | Gold & Platinum PPO Medical Plans
The Blue Shield Preferred Provider Organization (PPO) plans allow you to direct your own care. If you receive care from a physician who is a
member of the network, a greater percentage of the entire cost will be paid by the insurance plan, however, you are not limited to the physicians
within the network and you may self-refer to specialists. If you obtain services using a non-network provider, please note that you will be
responsible for the difference between the covered amount and the actual charges, and you may be responsible for filing claims.

Finding a Medical Provider

Call (888) 256-1915 or go to www.blueshieldca.com. From the Blue Shield website, select “Find a Doctor.” After choosing
the type of doctor, and selecting your zip code, you will then be instructed to select a medical plan and sub plan:
• HMO - Plan Name: 2017 Small Business HMO Access+ | Sub Plan Name: Platinum Access+ HMO 0/20 OffEx
• PPO HSA - Plan Name: 2017 Small Business PPO Full | Sub Plan Name: Silver Full PPO Savings 2000/20 OffEx
• Gold PPO - Plan Name: 2017 Small Business PPO Full | Sub Plan Name: Gold Full PPO 250/35 OffEx
• Platinum PPO - Plan Name: 2017 Small Business PPO Full | Sub Plan Name: Platinum Full PPO 150/15 OffEx

Take advantage of the tools and resources available on www.blueshieldca.com. Once you register you will have access
to view your ID card, manage your claims, find providers, access the NurseHelp 24/7, take advantage of discount
programs and more.

Summary of Benefits and Coverage (SBC)
Health insurance issuers and group health plans are required to provide you with an easy-to-understand summary about your health plan’s
benefits and coverage, referred to as a Summary of Benefits and Coverage (SBC). This guide is designed to help you understand the medical plan
options offered to you by Surfline/Wavetrak, Inc.. Please refer to the SBC and carrier contracts provided by Blue Shield for additional plan details.

8