Document:

Exhibit 4.01

 

	
  COMMON STOCK

  	
  COMMON STOCK

  

 

WP

 

INCORPORATED UNDER THE
LAWS

OF THE STATE OF DELAWARE

 

THIS CERTIFICATE IS
TRANSFERABLE IN THE CITIES OF LOS ANGELES,

RIDGEFIELD PARK OR NEW
YORK

 

SEE REVERSE FOR
STATEMENTS RELATING

TO RIGHTS, PREFERENCES,

PRIVILEGES AND
RESTRICTIONS, IF ANY

 

CUSIP 94973H 10 8

 

THIS CERTIFIES THAT

 

IS THE RECORD
HOLDER  OF

 

FULLY PAID AND
NONASSESSABLE SHARES OF THE COMMON STOCK, $.01 PAR VALUE, OF

WELLPOINT HEALTH
NETWORKS INC.

 

transferable on the
books of the Corporation by the holder hereof in person or by duly authorized
attorney upon surrender of this certificate properly endorsed. This certificate
is not valid until countersigned and registered by the Transfer Agent and
Registrar.

WITNESS the facsimile
seal of the Corporation and the facsimile signatures of its duly authorized
officers.

Dated:

 

SECRETARY

 

 

CHAIRMAN AND CHIEF
EXECUTIVE OFFICER

 

 

 

COUNTERSIGNED AND
REGISTERED:

MELLON INVESTOR SERVICES
LLC

TRANSFER AGENT

AND REGISTRAR

 

BY

 

AUTHORIZED SIGNATURE

 

 

 

A statement of the
rights, preferences, privileges and restrictions granted to or imposed upon the
respective classes or series of shares and upon the holders thereof as
established, from time to time, by the Restated Certificate of Incorporation of
the Corporation and by any certificate of designations, and the number of
shares constituting each class and series and the designations thereof, may be
obtained by the holder hereof upon written request and without charge from the
Secretary of the Corporation at its corporate headquarters.

 

The shares of stock
represented by this certificate are subject to restrictions on ownership and
transfer. No Person shall Beneficially Own shares of Capital Stock in excess of
the Ownership Limit (as defined in Article VII, Section 14 of the Restated
Certificate of Incorporation of the Corporation). Subject to certain limited
specific exemptions, Beneficial Ownership of 5% or more of the outstanding
shares of any class of Capital Stock will exceed the Ownership Limit. These
provisions have been designed to ensure that the Corporation will not violate
the terms of the License Agreement between the Corporation and the Blue Cross
and Blue Shield Association (the “BCBSA”). The Corporation maintains at its
principal executive office a copy of the applicable requirements of the BCBSA
relating to such restrictions on ownership and transfer, as such requirements
may be amended from time to time, which are open to inspection by the
stockholders, at all reasonable times during office hours. Any Person who
attempts to beneficially own shares in violation of this limitation must
immediately notify the Corporation. All capitalized terms in this legend have
the meanings ascribed to them in the Corporation’s Restated Certificate of
Incorporation, as the same may be amended from time to time, a copy of which,
including the restrictions on ownership and transfer, will be sent without
charge to each stockholder who so requests. Upon the occurrence of any event
that would cause any Person to exceed the Ownership Limit (including without
limitation the expiration of a voting trust that entitled such Person to an
exemption from the Ownership Limit), all shares of Capital Stock Beneficially
Owned by such Person in excess of the Ownership Limit will automatically be
deemed Excess Shares and be transferred immediately to the Share Escrow Agent
and be subject to the provisions of the Corporation’s Restated Certificate of
Incorporation and the Share Escrow Agent Agreement, a copy of which the
Corporation maintains at its principal executive office. The foregoing summary
of the restrictions on ownership and transfer is qualified in its entirety by
reference to the Corporation’s Restated Certificate of Incorporation.

 

Pursuant to an amendment
to the License Agreement between the Corporation and the BCBSA, the Ownership
Limit referenced in the preceding paragraph has been amended as follows: (i)
for any Noninstitutional Investor, one share less than 5% of the Voting Power,
(ii) for any Institutional Investor, one share less than 10% of the Voting
Power, and (iii) for any Person, one share less than the number of shares of
Common Stock or other equity securities (or a combination thereof) representing
20% of the ownership interest in the Corporation.

 

The following abbreviations,
when used in the inscription on the face of this certificate, shall be
construed as though they were written out in full according to applicable laws
or regulations:

 

	
   

  	
  TEN COM

  	
  —

  	
  as tenants in common

  	
   

  
	
   

  	
  TEN ENT

  	
  —

  	
  as tenants by the
  entireties

  	
   

  
	
   

  	
  JT TEN

  	
  —

  	
  as joint tenants with
  right of

  	
   

  
	
   

  	
   

  	
   

  	
  survivorship and not
  as tenants

  	
   

  
	
   

  	
   

  	
   

  	
  in common

  	
   

  

 

 

 

	
   

  	
   

  	
  UNIF GIFT MIN ACT

  	
  —

  	
   

  	
  .........................
  Custodian .........................

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
  (Cust)

  	
  (Minor)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  under Uniform Gifts to
  Minors Act ..............................................................

  
	
   

  	
   

  	
   

  	
   

  	
                                             
  (State)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  UNIF TRF MIN ACT

  	
  —

  	
   

  	
  .......................
  Custodian (until age ..................)

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
  (Cust)

  	
  (Minor)

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
  under Uniform Transfers
  to Minors Act ...........................................

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
  (State)

  
									

 

Additional abbreviations
may also be used though not in the above list.

 

    FOR VALUE RECEIVED,                                                                     

hereby sell, assign and
transfer unto

 

 

                PLEASE INSERT SOCIAL SECURITY OR OTHER

                IDENTIFYING NUMBER OF ASSIGNEE

 

 

 

 

(PLEASE PRINT OR
TYPEWRITE NAME AND ADDRESS, INCLUDING ZIP CODE, OF ASSIGNEE)

 

 

Shares of the capital
stock represented by the within Certificate, and do hereby irrevocably
constitute and appoint

 

Attorney to transfer the
said stock on the books of the within named Corporation with full power of
substitution in the premises.

Dated

X

X

 

NOTICE:

 

 

 

THE SIGNATURE(S) TO THIS
ASSIGNMENT MUST CORRESPOND WITH THE NAME(S) AS WRITTEN UPON THE FACE OF THE
CERTIFICATE IN EVERY PARTICULAR, WITHOUT ALTERATION OR ENLARGEMENT OR ANY
CHANGE WHATEVER.

 

Signature(s) Guaranteed

 

 

 

By

THE SIGNATURE(S) SHOULD
BE GUARANTEED BY AN ELIGIBLE GUARANTOR INSTITUTION (BANKS, STOCKBROKERS,
SAVINGS AND LOAN ASSOCIATIONS AND CREDIT UNIONS WITH MEMBERSHIP IN AN APPROVED
SIGNATURE GUARANTEE MEDALLION PROGRAM), PURSUANT TO S.E.C. RULE 17Ad-15.Exhibit 10.18

 

 

HUMAN RESOURCES

 

Benefits for

Your Life and Career

 

 

2003 OFFICER BENEFITS ENROLLMENT GUIDE

 

 

2003 FlexPoint Enrollment Guide

 

 

How to Use
This Guide

 

Your 2003 Officer Benefits Enrollment Guide contains
information on the FlexPoint
Benefits Program and the FlexExec
Officer Benefits Program of WellPoint Health Networks, Inc. (“WellPoint”) and
its affiliates. Use this FlexPoint
Enrollment Guide for:

 

Enrollment Procedures for Newly-Hired Officers

 

Enrollment procedures for new Officers are on page 11 of this Guide.

 

Open Enrollment

 

An overview of the 2003 FlexPoint
Benefits Program and enrollment procedures is on pages 6-10. You must enroll through ASC Online at home.wellpoint.com
or on the Internet at asconline.wellpoint.com. You only need to enroll
if you would like to change your benefit election(s), make corrections and/or
elect Flexible Spending Account(s) for 2003.

 

Read the FlexPoint
Enrollment Guide carefully to
determine the benefits that best suit your needs for 2003. Enroll for 2003 benefits from October 28, 2002 through
November 8, 2002.

 

Benefit Information

 

Explanations of the 2003 benefits are included for your review.

 

FlexPoint

 

FlexPoint benefits provide you and your family with health care, life
insurance and disability coverage options. You can change most of your benefits
once a year in order to meet your needs for the upcoming year. Read this
section carefully
because you will
not be able to change your
elections during the year except as a result of a qualified mid-year change or
if you meet special enrollment requirements.

 

FlexExec

 

An overview of the additional benefits provided to WellPoint Officers
is included.

 

Balanced Life Benefits

 

WellPoint offers you a wide spectrum of benefits in addition to our FlexPoint benefits to assist you in balancing
your career and your personal life. You can take advantage of many of the
benefits at any time during the year.

 

Financial Future and Retirement

 

Brief descriptions of the Pension Accumulation Plan, 401(k) Retirement
Savings Plan and Employee Stock Purchase Plan are included.

 

Mid-Year Changes

 

WellPoint Officers experience a number of changes throughout the year
that could affect their
benefits, including marriage, birth, and change of employment. Review this
section to learn more about mid-year changes and what to do.

 

COBRA

 

An explanation of COBRA coverage is included for your review.

 

Important Information

 

An explanation of important legislation is included.

 

Important Telephone Numbers and Claims Addresses

 

A listing of phone numbers for providers and addresses for submitting
claims is included.

 

i

 

About This Guide

 

This Guide does not serve as a guarantee of continued
employment or benefits. WellPoint policies on hiring, discharge, layoff, and
discipline are in no way affected by the programs described here. In
particular, nothing in this booklet alters WellPoint’s at-will employment
policy which provides that employment with WellPoint is not for a specified
period of time and can be terminated by either WellPoint or the associate at
any time, with or without cause or advance notice.

 

In addition, WellPoint reserves the right to amend or
discontinue the WellPoint plans—or any part of them—with or without notice, at any
time at WellPoint’s sole discretion. If there is a discrepancy between this
document and the plan documents, the provisions of the plan documents will
govern.

 

ii

 

Benefits for Your Life and Career

 

Table
of Contents

 

	
  Your 2003 Benefits Program

  	
  2

  
	
   

  	
   

  
	
  FlexPoint

  	
  2

  
	
   

  	
   

  
	
  FlexExec

  	
  3

  
	
   

  	
   

  
	
  Comprehensive Executive
  Non-Qualified Retirement Plan

  	
  3

  
	
   

  	
   

  
	
  Additional Plans

  	
  3

  
	
   

  	
   

  
	
  FlexPoint Eligibility

  	
  4

  
	
   

  	
   

  
	
  How FlexPoint
  Works

  	
  6

  
	
   

  	
   

  
	
  Domestic Partner Coverage

  	
  7

  
	
   

  	
   

  
	
  Open Enrollment Procedures for Current WellPoint
  Officers

  	
  9

  
	
   

  	
   

  
	
  Enrollment Procedures for Newly-Hired Officers

  	
  11

  
	
   

  	
   

  
	
  FlexPoint Benefits Information

  	
  12

  
	
   

  	
   

  
	
  Your Medical Coverage

  	
  12

  
	
   

  	
   

  
	
  Your Dental Coverage

  	
  22

  
	
   

  	
   

  
	
  Your Vision Coverage

  	
  24

  
	
   

  	
   

  
	
  Your Life Insurance Coverage

  	
  25

  
	
   

  	
   

  
	
  Your Dependent Life
  Insurance Coverage

  	
  27

  
	
   

  	
   

  
	
  • Spouse/Domestic Partner

  	
  27

  
	
   

  	
   

  
	
  • Child

  	
  27

  
	
   

  	
   

  
	
  Your Accidental Death and Dismemberment (AD&D) Coverage

  	
  28

  
	
   

  	
   

  
	
  Your Flexible Spending Accounts

  	
  29

  
	
   

  	
   

  
	
  • Health Care

  	
  29

  
	
   

  	
   

  
	
  • Dependent Day Care

  	
  30

  
	
   

  	
   

  
	
  FlexExec

  	
  32

  
	
   

  	
   

  
	
  Officer
  Physical Exams

  	
  32

  
	
   

  	
   

  
	
  Group
  Universal Life Insurance

  	
  32

  
	
   

  	
   

  
	
  Your
  Disability Coverage

  	
  33

  
	
   

  	
   

  
	
  Comprehensive
  Non-Qualified Retirement Plan

  	
  34

  
	
   

  	
   

  
	
  Balanced Life Benefits

  	
  37

  
	
   

  	
   

  
	
  Employee
  Assistance and Work/Life Program

  	
  37

  
	
   

  	
   

  
	
  MedCall

  	
  37

  
	
   

  	
   

  
	
  Tuition
  Assistance

  	
  37

  
	
   

  	
   

  
	
  Work
  On Wellness

  	
  38

  
	
   

  	
   

  
	
  Time
  Off

  	
  38

  
	
   

  	
   

  
	
  Financial Future and Retirement Benefits

  	
  39

  
	
   

  	
   

  
	
  Pension
  Accumulation Plan

  	
  39

  
	
   

  	
   

  
	
  401(k)
  Retirement Savings Plan

  	
  39

  
	
   

  	
   

  
	
  Employee
  Stock Purchase Plan

  	
  40

  
	
   

  	
   

  
	
  Mid-Year Changes

  	
  41

  
	
   

  	
   

  
	
  Continuing Health Care Coverage (“COBRA”)

  	
  44

  
	
   

  	
   

  
	
  Important Information

  	
  46

  
	
   

  	
   

  
	
  Important Telephone Numbers

  	
  48

  
	
   

  	
   

  
	
  Important Addresses for Claims

  	
  49

  

 

1

 

2003 Benefits Program

 

Here’s a quick look at the benefits offered to Officers of WellPoint
Health Networks Inc.

 

	
  FlexPoint

  	
   

  	
   

  
	
   

  	
   

  	
   

  
	
  Plan

  	
   

  	
  Options

  
	
   

  	
   

  	
   

  
	
  Medical

  	
   

  	
  • PPO, Group or
  HMOs
• Waive coverage

  
	
  Dental

  	
   

  	
  • Dental Net
  (available only in California)
• Standard Dental Plan
• Enhanced Dental Plan
• Waive coverage

  
	
  Vision

  	
   

  	
  Vision Service Plan

  Waive coverage

  
	
  Life Insurance

  	
   

  	
  $50,000

  1 times your benefit salary

  2 times your benefit salary

  3 times your benefit salary

  4 times your benefit salary

  Waive coverage

  
	
  Accidental Death and Dismemberment (AD&D)
  Insurance

  	
   

  	
  • 1 times your
  benefit salary

  (minimum coverage required)
• 2 times your benefit salary

  3 times your benefit salary

  4 times your benefit salary

  
	
  Dependent
  Life Insurance 

  	
   

  	
   

  
	
  Spouse/Domestic
  Partner:

  	
   

  	
  $5,000

  1/2 your benefit salary

  1 times your benefit salary

  Waive coverage

  
	
  Each
  Child*:

  	
   

  	
  $5,000

  $10,000

  $25,000

  Waive coverage

  
	
  Flexible Spending Accounts

  	
   

  	
  Health care up to $5,000

  Dependent daycare up to $5,000

  

 

*                      Amount payable depends on age of child. See
page 27.

 

2

 

FlexExec

 

These benefit plans are provided for all WellPoint Officers
automatically—no enrollment is required.

 

	
  Plan

  	
   

  	
  Options

  
	
   

  	
   

  	
   

  
	
  Officer Physical Exams

  	
   

  	
  Available to Vice Presidents and above with one year of service

  
	
  Group Universal Life

  	
   

  	
  2 times compensation* for Vice Presidents and General Managers

  3 times compensation* for Senior Vice Presidents and above

  
	
  Short-Term Disability

  	
   

  	
  Maximum of 26 weeks salary continuance

  
	
  Long-Term Disability

  	
   

  	
  60% of compensation** for Vice Presidents and General Managers

  70% of compensation** for Senior and Executive Vice Presidents

  

 

*                      Base salary as of September 1, 2002 plus
target management bonus

 

**               Base salary as of September 1, 2002 plus
target management bonus and commissions received from 9/1/2001 through 8/31/2002

 

Comprehensive
Executive Non-Qualified Retirement Plan

 

	
  Plan/Feature

  	
   

  	
  Options

  
	
   

  	
   

  	
   

  
	
  Supplemental 401(k) Deferral

  	
   

  	
  You may defer 1% – 6% of your eligible compensation after
  contributing the annual maximum to the 401(k) plan and also before becoming
  eligible for the Company match; deferrals receive a Company matching
  contribution

  
	
  Salary Deferral

  	
   

  	
  You may defer 1% – 60% of your base salary

  
	
  Management Bonus Deferral

  	
   

  	
  You may defer 1% – 100% of your 2003 bonus to be paid in 2004

  
	
  Car Allowance Deferral

  (You
  may elect to defer your car allowance, receive it as taxable income, or
  decline it and receive mileage reimbursement.)

  	
   

  	
  $4,800 annually for Vice Presidents and General Managers

  $7,200 annually for Senior Vice Presidents

  $9,600 annually for Executive Vice Presidents and above

  
	
  Supplemental Pension Plan

  	
   

  	
  WellPoint automatically makes contributions for compensation in
  excess of $200,000; 5-year vesting applies

  

 

Additional
Plans

 

	
  Plan

  	
   

  	
  Options

  
	
   

  	
   

  	
   

  
	
  WellPoint 401(k) Retirement Savings Program

  	
   

  	
  Highly compensated may defer 1% – 8% of your eligible compensation;
  Company match applies (see page 39 for details)

  
	
  Employee Stock Purchase Plan

  	
   

  	
  You may contribute between $20 and $817.30 per pay period (see page
  40 for details)

  

 

3

 

FlexPoint Eligibility

 

All full-time Officers are eligible for FlexPoint benefits on the first of the month coinciding with
or following one calendar month of employment. For example, if you begin work
on July 15, you’ll be eligible to participate in FlexPoint on September 1. If you begin work on July 1,
you’ll be eligible to participate on August 1.

 

If you are rehired within one year of termination, you are eligible for
FlexPoint benefits on the first
of the month following your rehire date.

 

Dependents

 

You may only enroll your eligible dependents in FlexPoint benefits. Enrolling dependents who are not eligible is a
violation of Company policy that is subject to disciplinary action up to and
including termination of employment. Domestic partner coverage is
available for health and life insurance benefits. See pages 7-8.

 

Eligible dependents include:

 

•                       Your spouse/domestic partner

 

•                       Your or your spouse/domestic partner’s
unmarried children through age 18 who are your dependents for income tax
purposes. Legally-adopted children, stepchildren and any child for whom you or
your spouse/domestic partner is a legal guardian are eligible under the same
terms as your own natural children.

 

•                       Your or your spouse/domestic partner’s
unmarried children, age 19 through 24, who are your dependents for income tax
purposes and enrolled for 12 or more credits per semester (or equivalent
full-time basis) in an accredited college, university, or post-high-school
trade or technical school. You will be required to provide proof of full-time
student status.

 

•                       Your or your spouse/domestic partner’s
unmarried children who are your dependents for income tax purposes and who are
declared by a physician to be incapacitated or disabled. A physician’s note is
required, and generally the child must have been covered under the plan at the
time of disability.

 

Note: You may not be covered as an associate and as a dependent on
WellPoint’s medical, dental, vision or life insurance plans. For example, if
you and your spouse are both employed at WellPoint, you may elect to cover your
spouse for medical, dental and vision. However, your spouse may not also elect
those coverages as an associate. Or, both you and your spouse may each elect to
be covered as associates. Additionally, you may not have duplicate coverage for
your children (i.e., both parents may not elect medical, dental, vision and/or
life insurance for the children).

 

4

 

When Coverage Ends

 

Your coverage under the medical, dental and vision plans will end on
the last day of the month of termination of your employment with WellPoint. You
may be eligible to continue your WellPoint health coverage through COBRA (see
page 44). Employee life, AD&D, dependent life, STD and LTD end on your last
day of employment with WellPoint. You may be able to convert your employee life
insurance. Coverage for associates whose positions are eliminated as part of a
reduction-in-force will have their medical, dental and vision coverage continued
for three months following the last day of the month in which they are
terminated, as specified in the release agreement. Other situations in which
your coverage will be terminated are listed below, along with the same kind of
information for your dependents.

 

All coverage will terminate at the earliest time specified below:

 

1.                   For the medical, dental and vision plans, on the last day of the month
you cease to be an eligible associate (such as termination of employment,
retirement, change in employment status or for any other reason).

 

2.                   For the employee life, dependent life, AD&D, STD and LTD plans, on
the date you cease to be an eligible associate (such as termination of
employment, retirement, change in employment status or for any other reason).

 

3.                   Upon discontinuation or termination of any plan, when such plan ends.
The plans may be terminated or amended without notice to you.

 

4.                   Upon non-payment of any required associate contribution.

 

Your dependent(s) coverage will cease at the earliest time specified
below:

 

1.                   When your coverage terminates.

 

2.                   On the last day of the calendar month when your dependent(s) cease to
be eligible, depending on plan provisions.

 

3.                   Upon non-payment of any required associate contribution.

 

5

 

How FlexPoint
Works

 

Coverage Levels

 

In addition to deciding which medical, dental, and vision options you
want for yourself, you may also decide if you want dependent coverage.
WellPoint offers four levels of coverage. You can select coverage for:

 

•                       Yourself only

 

•                       Yourself plus Spouse/Domestic
Partner

 

•                       Yourself plus Child(ren)

 

•                       Yourself plus Family
(Spouse/Domestic Partner and Child(ren))

 

The Pretax Advantage

 

With FlexPoint, you pay
your share of the cost for most of your benefits on a pretax basis (excluding
domestic partner coverage*). This means your contributions will be deducted
from your pay BEFORE Social
Security, Medicare, federal, state, and local income taxes are calculated and
withheld. This way, your taxable income is reduced and you pay less tax.

 

*                      For more information, please refer to the
Domestic Partner Guide.

 

Pretax

 

•                       Medical

 

•                       Dental

 

•                       Vision

 

•                       Flexible Spending
Accounts—Health Care and Dependent Day Care

 

Post-tax

 

•                       Employee Life

 

•                       Dependent Life Insurance

 

•                       Accidental Death and
Dismemberment (AD&D)

 

•                       Domestic Partner Coverage

 

Coverage During a Leave of Absence

 

If you go out on an unpaid leave of absence, you are given the option
to discontinue some or all of your FlexPoint
benefits as of the date the leave begins. You will have the option to reinstate
these benefits when you return from the leave. If you continue your coverage
during a leave of absence, it is your responsibility to make biweekly payments
for the cost of your benefits to the Leave of Absence Unit.

 

Changes to Coverage During a Leave of Absence

 

•                       Changes to life insurance, spouse/ domestic
partner life, child life, and AD&D do not become effective until the later
of the following:

 

•                       January 1, 2003, or

 

•                       The date of your return to active employment
status.

 

•                       Changes that may result in an increase in the
amount or volume of life insurance will not take effect while on a leave of
absence; they are delayed until your return to active employment.

 

6

 

Domestic
Partner Coverage

 

FlexPoint offers limited benefits coverage to domestic partners. Officers
who are eligible for FlexPoint
may enroll their domestic partners and/or children of domestic partners in
medical,* dental, vision and life insurance coverage.

 

For the purpose of FlexPoint,
a domestic partnership consists of two adults of the same or opposite sex who
have chosen to share their lives in a committed relationship equivalent to that
of married persons, and who reside together and share a mutual obligation of
support for the basic necessities of life.

 

Eligibility

 

To qualify for benefits, the associate and domestic partner must meet ALL of the following criteria:

 

•                       Each person is the other’s sole domestic
partner and intends to remain so indefinitely.

 

•                       Neither person is married or legally
separated from anyone else.

 

•                       Each person is at least 18 years of age and
mentally competent to consent to the terms of the Declaration of Domestic
Partnership.

 

•                       The associate and domestic partner are not
related by blood to a degree of closeness that would prohibit legal marriage in
the state in which they reside.

 

•                       Both persons currently reside in the same
residence and intend to do so indefinitely.

 

•                       Both persons are jointly responsible for
basic living expenses incurred during the domestic partnership.

 

•                       Neither partner has had a different domestic
partner within the last 12 months from the date of the execution of the
Declaration of Domestic Partnership (this condition does not apply if the
previous domestic partner is deceased).

 

•                       Both persons have executed a domestic
partnership agreement and/or registered as domestic partners in a jurisdiction
that authorizes such agreements and/or registries OR at least TWO of the following statements are true:

 

•                       Both persons have lived together continuously
for the past 12 months;

 

•                       The associate has designated the domestic
partner as a beneficiary under his/her will, or the domestic partner has
designated the associate as a beneficiary under his/her will;

 

•                       The associate has granted his or her domestic
partner powers under a durable power of attorney, or the domestic partner has
granted the associate powers under a durable power of attorney;

 

•                       The associate has previously designated the
domestic partner as a beneficiary under his/her life insurance policy, or the
domestic partner has previously designated the associate as a beneficiary under
his/her life insurance policy;

 

•                       Both persons share a joint bank account;

 

•                       Both persons are cosigners of a lease or
deed;

 

•                       Both persons are named on the same car
insurance policy.

 

 

*                      Not all HMOs offer domestic partner coverage
(see page 21). This coverage is available in all states under the PPO or Group
Plan.

 

7

 

Certification

 

If you wish to elect domestic partner benefits, you must complete a
Declaration of Domestic Partnership and return it for approval before any
domestic partner benefits can be activated. The declaration form will be mailed
to you when you elect domestic partner benefits. Both you and your domestic
partner are required to sign the declaration and return it within 14 days of
receipt.

 

Eligible Dependents

 

In addition to health and life insurance coverage for your domestic
partner, you may also elect health and life coverage for the qualified children
of your domestic partner. Your domestic partner’s children are eligible for
coverage if they are:

 

•                                          Unmarried;

 

•                                          Primarily dependent on you or your domestic
partner for support;

 

•                                          Living with you and your domestic partner in
a regular parent-child relationship;

 

•                                          Within the age/student requirements of the
plan benefits; and

 

•                                          Eligible to be claimed by you or your
domestic partner as a dependent as defined in Internal Revenue Code section
152.

 

Cost of Coverage

 

	
  Coverage

  	
   

  	
  Associate

  Biweekly Cost

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  •                                          Associate & Domestic Partner

  	
   

  	
  Same

  	
   

  
	
  •                                          Associate & Spouse

  	
   

  	
   

  	
   

  
	
  •                                          Associate & Domestic Partner(s)
  Child(ren)

  	
   

  	
  Same

  	
   

  
	
  •                                          Associate & Associate’s Child(ren)

  	
   

  	
   

  	
   

  
	
  •                                          Associate, Associate’s Child(ren) &
  Domestic Partner’s Child(ren)

  	
   

  	
   

  	
   

  
	
  •                                          Associate, Spouse & Child(ren)

  	
   

  	
  Same

  	
   

  
	
  •                                          Associate, Domestic Partner &
  Associate’s Child(ren) and/or Domestic Partner’s Child(ren)

  	
   

  	
   

  	
   

  

 

The portion of your contribution that is attributable to coverage for
your domestic partner and/or your domestic partner’s child(ren) will be paid on
an after-tax basis.

 

Tax Consequences

 

The IRS has determined that
if you receive health benefits for your domestic partner and/or his or her
children, AND your domestic partner
and his or her children are not your dependents as defined by the IRS, you must
pay federal income tax on the value of the benefits you received. The IRS
defines the value of these benefits as the amount it would cost you to obtain
the insurance for your partner and each of your partner’s children at group
policy rates. Because there are tax consequences associated with domestic
partner coverage, we recommend you consult a tax advisor before electing this
coverage.

 

You may view and print a copy of the Domestic Partner
Guide from WorkSite (home.wellpoint.com). Go to Corporate Links>Human
Resources>Library> Benefits. If you are unable to view or print these
materials, call the Associate Service Center at (877) 342-5272 to have a copy
sent to you.

 

8

 

Open
Enrollment Procedures for Current WellPoint Officers

 

Comprehensive Executive Non-Qualified
Retirement Plan

 

As in prior years, you will make your Comprehensive Executive
Non-Qualified Retirement Plan elections by completing a FlexExec enrollment form. Web enrollment is not
available for the Comprehensive Executive Non-Qualified Retirement Plan.

 

FlexPoint

 

Your FlexPoint
elections for 2003 will be in effect from January 1 through December 31,
provided you remain eligible for benefits. Each year, during the Open
Enrollment period, you have the opportunity to change your coverage for the
following plan year.

 

Open Enrollment will be from October 28, 2002 through November 8, 2002.

 

When you log on for Web enrollment to make changes, you must enter your
user ID, as well as your password. Using your password serves as both your
signature and your authorization to process benefit changes.

 

Before you enroll, give careful consideration to the benefits you will
need for the 2003 calendar year. Unless you have a qualified mid-year change
(see Mid-Year Changes on page 41), you may not make any changes to your
enrollment selections until 2004.

 

If You Need to Make Changes...

 

1.                                      Review this FlexPoint
Enrollment Guide and select your benefit coverages. If you have specific
questions about coverages, please contact the plan provider directly. Customer
Service telephone numbers are listed in the Medical Comparison Chart (pages
14-19) and the Dental Comparison Chart (page 23).

 

2.                                      Log on to ASC Online to make your 2003
benefit elections from October 28, 2002 through November 8, 2002.

 

3.                                      You will receive a Confirmation Statement
along with any necessary forms at the end of the Open Enrollment period. If you
do not receive a Confirmation Statement by December 2, 2002, please contact the
Associate Service Center immediately.

 

4.                                      Check your Confirmation Statement carefully. If you need to make any changes or
corrections, call
the Associate Service Center at (877) 342-5272 before December 20, 2002.

 

Enroll Via ASC Online

 

During this open enrollment period, you can make FlexPoint changes on ASC Online. Simply
type home.wellpoint.com from your browser at work to access the
enrollment site from the WellPoint Intranet. You can also access the enrollment
site from home at asconline.wellpoint.com. You will be asked to enter
your user ID as well as your password.

 

Important: After you scroll through
and make the changes you want, you must click “Submit.” Your elections are not
final until you click the “Submit” button and the summary of elections screen
appears.

 

9

 

If You Do Not Log On to ASC Online to Enroll

 

•                                          You will receive your 2002 benefit coverages
(except for your Flexible Spending Accounts) at the new 2003 contribution
levels.

 

•                                          You will not participate in the Health Care
or Dependent Day Care Flexible Spending Accounts. You must log on to ASC Online to authorize
Health Care and Dependent Day Care Spending Account deductions for 2003.

 

ASC Online

 

Log on at work at

home.wellpoint.com

 

or at home at

asconline.wellpoint.com

 

Confirmation Statements

 

•                                          A Confirmation Statement will be mailed to
your home at the end of the enrollment period. You may also review your
elections on-line at any time.

 

•                                          Check your Confirmation Statement carefully. If you need to make any changes or
corrections, or fix omissions, call the Associate Service Center before December 20, 2002. You cannot make changes or corrections
after December 20, 2002.

 

Keep your Confirmation Statement for your records.

 

Forms

 

Depending upon your elections, you may be required to complete and
submit additional information.

 

•                                          If you are newly enrolling or are adding a
new dependent in an HMO or Dental Net (California associates only), you must
complete an HMO and Dental Net enrollment form.

 

•                                          A Declaration of Domestic Partnership is
required if you are adding your domestic partner to your coverage for the first
time.

 

•                                          An Evidence of Insurability (EOI) form is
required if you select a life insurance option that is two levels greater than
your existing coverage. If you increase coverage for your spouse/domestic
partner by one level or more, an EOI form is required. Should you increase
child life insurance by two levels or more, you will need to complete an EOI
form for each child.

 

EOI forms will be sent to your home address after November 14,2002.

 

For coverage to be effective for January 1, 2003, all forms must be
returned by December 20, 2002.

 

Deductions and Pay Periods in 2003

 

There will be 26 pay periods in 2003. Your first benefit deductions for
2003 will begin with your January 3, 2003 paycheck. If you notice any errors or omissions on this paycheck, contact the
Associate Service Center immediately. No corrections can be made after January
17, 2003.

 

Questions?

 

If you have any questions about your FlexPoint
options or procedures, contact the Associate Service Center. If you have
specific medical or dental coverage questions, please call the Customer Service
numbers listed in the Medical Comparison Chart (pages 14–19) and the Dental
Comparison Chart (page 23).

 

10

 

Enrollment
Procedures for Newly-Hired Officers

 

Comprehensive Executive Non-Qualified
Retirement Plan

 

You will make your Comprehensive Executive Non-Qualified Retirement
Plan elections by completing enrollment forms, which will be sent to you under
separate cover. Web enrollment is not available for the Comprehensive Executive
Non-Qualified Retirement Plan.

 

FlexPoint

 

Before you enroll, give careful consideration to the benefits you will
need for the 2003 calendar year. Unless you have a qualified mid-year change
(see Mid-Year Changes on page 41), you may not make any changes to your enrollment selections until 2004.

 

Enrollment will be conducted through ASC Online, a Web enrollment
system where associates enter their benefit selections. This system will be
available 7days a week, during your enrollment period.

 

Steps

 

1.                                      Review this 2003 FlexPoint Enrollment Guide and select your benefit
coverages. To assist you in your provider selections, HMO and PPO directories
are available on WorkSite or by contacting your local Human Resources office.
If you have questions about medical or dental coverage, please contact the
providers directly at the Customer Service phone numbers listed in the Medical
Comparison Chart (pages 14–19) and the Dental Comparison Chart (page 23).

 

2.                                      Complete the Enrollment Worksheet and select
your coverage levels prior to enrolling.

 

3.                                      Log on to ASC Online to make your 2003
benefits elections. Simply type home.wellpoint.com from your browser at
work to access the enrollment site from the WellPoint Intranet. You can also
access the enrollment site from home at asconline.wellpoint.com. You
will be asked to enter your user ID as well as your password. Using your
password serves as both your signature and your authorization to process
benefit elections.

 

4.                                      You will receive a Confirmation Statement
after you complete your enrollment. If you do not receive a Confirmation
Statement within two weeks of enrolling, contact the Associate Service Center.

 

Default Coverage—If You Don’t Enroll

 

If you do not make your elections within the time period indicated on
your Enrollment Worksheet, you will be assigned default coverage automatically. Default coverage provides minimal benefits
for you only—not your dependents. With default coverage, you receive the
following benefits:

 

•                                          PPO or Group Medical, associate only coverage
with $1,000 deductible

 

•                                          $50,000 in life insurance

 

•                                          One times your benefit salary in Accidental
Death and Dismemberment (AD&D) insurance

 

•                                          No Flexible Spending Account participation

 

If coverage is defaulted, you must wait until the next annual
enrollment period to elect other coverage unless you qualify for a midyear
change that allows you to change some, but not all, coverages.

 

11

 

FlexPoint Benefits Information

 

Your
Medical Coverage

 

The medical options in FlexPoint are designed to meet the needs
of individuals with varying personal situations. Depending on where you live
and work, you may be able to choose a preferred provider organization (PPO), a
health maintenance organization (HMO) or a group plan if you live where there
is no PPO or HMO available. Your medical options are based on both your home
address and/or your Company mail drop. Please carefully review provider
directories (available on WorkSite or at your local HR office) before making an
election. In making your choice, it’s important that you read and understand
the benefits available to you, as well as the limitations and exclusions. The
information in this Enrollment Guide is only a summary—refer to your Summary
Plan Description for more information.

 

•                                          Consider the way you now receive—or would
like to receive—medical care, and identify your alternatives. HMOs generally
require you to pay a small fee (copay) when you use network services and
provide no benefits when you use a provider outside the network. With the PPO,
you may have to satisfy a deductible and coinsurance. However, you may use a
non-network provider if you are willing to share more of the cost.

 

•                                          Also find out whether your current providers
participate in an available HMO or PPO. If you’re enrolling in an HMO and will
be a new patient with a particular primary care physician, call the physician’s
office to determine whether he/she is accepting new patients.

 

Special Considerations

 

If you have coverage under another group medical plan,
you have the option to waive your FlexPoint
medical coverage. If you waive medical coverage, you must certify coverage with
another group plan (part-time associates do not need to certify coverage). For
example, you may be covered under your spouse’s plan. You can waive coverage and
receive a credit, which is taxable income in your paycheck. Part-time
associates are not eligible for flex credits.

 

If you elect an HMO (for the first time), or add
dependents to your HMO coverage, you must
submit an HMO Enrollment Form no later than December 20, 2002 (or the effective
date of your coverage for 2003 new hires), or you will be assigned a
provider.

 

If you have a qualified mid-year change (see page 41),
you must notify the Associate Service Center within 31 days of the change.

 

12

 

Claims Procedures

 

If you choose the PPO, your provider will file claims for you and your
covered dependents when you receive care in-network. For non-network providers
or if you choose the Group Plan, your provider may use a universal claim form
and mail it to the claims address on your ID card. You can obtain a claim form
by calling Customer Service at (800) 234-0111 or by downloading a claim form
from Member
Services at www.bluecrossca.com
or from WorkSite at home.wellpoint.com> Corporate
Links>Forms>Benefits.

 

All PPO and Group claims should be mailed to: WellPoint, P.O. Box 4109,
Woodland Hills, California 91365, Attn: Associate Claims Unit. Be sure to use a
separate claim form for each patient and provider.

 

For mail order prescriptions, send your order to: Prescription Drug
Program-Mail Service, P.O. Box 961025, Fort Worth, TX 76161-9863.

 

There may be some medications you cannot order through this program.
Call (866) 274-6825 to find out if you can order your medicine through the Mail
Service.

 

Associates in Georgia

 

If you choose the PPO, your provider will file claims for you and your
covered dependents when you receive care in-network. For non-network providers,
your provider may use a universal claim form and mail it to the claims address
on your ID card. You can obtain a claim form by calling Customer Service at
(800) 441-2273 or by downloading a claim form from Member Services at www.bcbsga.com.

 

Claims should be mailed to: Blue Cross and Blue Shield of Georgia, P.O.
Box 9907, Columbus, GA 31908-6007.

 

Associates in Missouri

 

If you choose the PPO, your provider will file claims for you and your
covered dependents when you receive care in-network. For non-network providers,
your provider may use a universal claim form and mail it to the claims address
on your ID card.

 

For BCBSMo, you can obtain a claim form by calling Customer Service at
(800) 556-6769 or by downloading a claim form from Member Services at www.bcbsmo.com.

 

PPO claims should be mailed to: Blue Cross and Blue Shield of Missouri,
P.O. Box 14882, St. Louis, MO 63178-4882.

 

HMO claims should be mailed to: BlueCHOICE, P.O. Box 66834, St. Louis,
MO 63166-6834.

 

For HealthLink, you can obtain a claim form by calling Customer Service
at (800) 624-2356 or by downloading a claim form from Member Services at www.healthlink.com.

 

PPO claims should be mailed to:

HealthLink, P.O. Box 419104, St. Louis, MO 63141-9104.

 

HMO claims should be mailed to:

HealthLink, P.O. Box 411580, St.
Louis, MO 63141-1580.

 

Medical Comparison Chart

 

The Medical
Comparison Chart has been designed to help you understand the differences
between plans. Carefully review this information before making your benefit
selection.

 

Note:  You continue to be responsible for all
copays, even after you reach the out-of-pocket maximum.

 

13

 

Medical
Comparison Chart

 

	
   

  	
   

  	
  PPO

  	
   

  

 

Deductible(1)

 

	
   

  	
   

  	
  250

  	
   

  	
  500

  	
   

  	
  1000

  	
   

  
	
  Individual

  	
   

  	
  $

  	
  250

  	
   

  	
  $

  	
  500

  	
   

  	
  $

  	
  1,000

  	
   

  
	
  Family

  	
   

  	
  $

  	
  750

  	
   

  	
  $

  	
  1,500

  	
   

  	
  $

  	
  3,000

  	
   

  

 

Out-of-Pocket
Maximum(2)

 

	
   

  	
   

  	
  250

  	
   

  	
  500

  	
   

  	
  1000

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Network

  	
   

  	
  Non-Network

  	
   

  	
  Network

  	
   

  	
  Non-Network

  	
   

  	
  Network

  	
   

  	
  Non-Network

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Individual

  	
   

  	
  $

  	
  2,500

  	
   

  	
  $

  	
  6,900

  	
   

  	
  $

  	
  3,500

  	
   

  	
  $

  	
  7,100

  	
   

  	
  $

  	
  4,500

  	
   

  	
  $

  	
  7,600

  	
   

  
	
  Family

  	
   

  	
  $

  	
  7,500

  	
   

  	
  $

  	
  20,700

  	
   

  	
  $

  	
  10,500

  	
   

  	
  $

  	
  21,300

  	
   

  	
  $

  	
  13,500

  	
   

  	
  $

  	
  22,800

  	
   

  

 

	
   

  	
   

  	
  Network
  Providers

  	
   

  	
  Non-Network
  Providers

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Hospital Services(3)

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Outpatient

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Skilled Nursing Facility

  	
   

  	
  80% after deductible; limited to 100 days/calendar year

  	
   

  	
  60% after deductible; limited to 100 days/calendar year

  
	
  Professional Services

  	
   

  	
   

  	
   

  	
   

  
	
  Office Visits

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% after deductible

  
	
   

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
  60% after deductible

  
	
   

  	
   

  	
  1000

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Well Baby Care:

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  • Office Visits

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% after deductible

  
	
   

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
  60% after deductible

  
	
   

  	
   

  	
  1000

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  • Immunizations

  	
   

  	
   

  	
   

  	
  $0 copay

  	
   

  	
  60% after deductible

  
	
  Annual Routine Exam

  ($300 maximum, including Well Woman exam)

  	
   

  	
  100% covered (does not apply toward deductible)

  	
   

  	
  60% after deductible

  
	
  Well Woman
  Exams:

  ($300
  maximum, included in Annual Routine Exam)

  	
   

  	
   

  	
   

  	
   

  
	
  • Office Visit

  	
   

  	
  100% covered (does not apply toward deductible)

  	
   

  	
  60% after deductible

  
	
  • Mammogram

  	
   

  	
  100% covered (does not apply toward deductible)

  	
   

  	
  60% after deductible

  
	
  • Pap Smear

  	
   

  	
  100% covered (does not apply toward deductible)

  	
   

  	
  60% after deductible

  
	
  X-ray and Lab Tests

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Emergency Medical Services

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Services (at hospital)

  	
   

  	
  80% after deductible

  	
   

  	
  80% after deductible

  
	
  Hospital Emergency Room

  	
   

  	
  80% after deductible

  	
   

  	
  80% after deductible

  
	
  Maternity

  	
   

  	
   

  	
   

  	
   

  
	
  Hospital

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Office Visits

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% after deductible

  
	
   

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
  60% after deductible

  
	
   

  	
   

  	
  1000

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Infertility Diagnostic Procedures

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Mental Health Care/

  Substance Abuse

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient (up to 30 days per
  calendar year)

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Outpatient (50 visit maximum/calendar
  year)

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Miscellaneous Services

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Chiropractic (26 visit maximum/calendar
  year)

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% ($25 maximum/visit–after deductible has been met)

  
	
   

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
   

  
	
   

  	
   

  	
  1000

  	
   

  	
  80% after deductible

  	
   

  	
   

  
	
  Acupuncture (26 visit maximum/calendar
  year)

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% ($25 maximum/visit–after deductible has been met)

  
	
   

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
   

  
	
   

  	
   

  	
  1000

  	
   

  	
  80% after deductible

  	
   

  	
   

  
	
  Physical Therapy/Physical Medicine

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Allergy Test

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% after deductible

  
	
   

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
   

  
	
   

  	
   

  	
  1000

  	
   

  	
  80% after deductible

  	
   

  	
   

  
	
  Allergy Treatment

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  
	
  Prescription Drugs(4)

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  $7 generic copay; 30-day supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary); 30-day supply

  	
   

  	
  $7 generic copay;  30-day
  supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary); 30-day supply

  
	
   

  	
   

  	
  $14 generic/$30 brand (formulary)

  $60 brand (non-formulary)

  mail order copay (90-day supply)

  	
   

  	
  $14 generic

  $30 brand (formulary)

  $60 brand (non-formulary)

  mail order copay (90-day supply)

  
	
   

  	
   

  	
  Infertility drugs not covered

  	
   

  	
  Infertility drugs not covered

  
	
  Customer Service Number

  	
   

  	
  (800)
  234-0111

  

 

(1)                                  Deductible–Copay amounts do not apply toward
the deductible.

 

(2)                                  Satisfying the smaller in-network coinsurance
and deductible will apply toward, but not satisfy, the larger out-of-network
coinsurance and deductible, excluding any copays. Satisfying the larger
out-of-network coinsurance and deductible will automatically satisfy the
smaller in-network coinsurance and deductible, excluding any copays. Copays do
not apply to the out-of-pocket maximum.

 

(3)                                  Hospital Services – Pre-certification is
required. You must initiate; failure to do so will result in a $250 additional
deductible for medically necessary care. Under no circumstances are benefits
payable for unnecessary care.

 

No pre-existing conditions apply.

 

(4)                                 If you choose a brand drug
when a generic is available, you will pay the generic copay plus 100% of the cost difference between
the brand and the generic retail or mail order cost.

 

14

 

	
   

  	
   

  	
  Group(1)

  	
   

  	
  Blue Cross
  HMO

  
	
  Deductible

  	
   

  	
  Deductible(2)

  	
   

  	
  Deductible

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Individual

  	
   

  	
  $

  	
  250

  	
   

  	
  $

  	
  500

  	
   

  	
  $

  	
  1,000

  	
   

  	
  There is no deductible; some services require a copay

  
	
  Family

  	
   

  	
  $

  	
  750

  	
   

  	
  $

  	
  1,500

  	
   

  	
  $

  	
  3,000

  	
   

  	
  There is no deductible; some services require a copay

  
	
  Out-of-Pocket Maximum

  	
   

  	
  Out-of-Pocket
  Maximum

  	
   

  	
  Out-of-Pocket Maximum

  
	
  Individual

  	
   

  	
  $

  	
  2,500

  	
   

  	
  $

  	
  3,500

  	
   

  	
  $

  	
  4,500

  	
   

  	
  $1,500

  
	
  Family

  	
   

  	
  $

  	
  7,500

  	
   

  	
  $

  	
  10,500

  	
   

  	
  $

  	
  13,500

  	
   

  	
  $3,000 (2 family members)

  
	
   

  	
   

  	
   

  	
   

  	
  $4,500 (3 or more family members)

  
	
  Hospital Services

  	
   

  	
  Hospital Services(3)

  	
   

  	
  Hospital Services

  
	
  Inpatient

  	
   

  	
  80% after deductible

  	
   

  	
  $250 room and board copay per admission

  
	
  Outpatient

  	
   

  	
  80% after deductible

  	
   

  	
  No charge

  
	
  Skilled Nursing Facility

  	
   

  	
  80% after deductible (limited to 100 days/calendar year)

  	
   

  	
  No charge (up to 100 days per year)

  
	
  Professional Services

  	
   

  	
  Professional Services

  	
   

  	
  Professional Services

  
	
  Office Visits

  	
   

  	
  80% after deductible

  	
   

  	
  $15 copay

  
	
  Well Baby Care:

  	
   

  	
   

  	
   

  	
   

  
	
  • Office Visits

  	
   

  	
  80% after deductible

  	
   

  	
  $15 copay

  
	
  • Immunizations

  	
   

  	
  100% covered

  	
   

  	
  No charge

  
	
  Annual Routine Exam

  	
   

  	
  100% covered (does not apply to deductible)

  ($300 maximum, including Well Woman exam):

  	
   

  	
  $15 copay

  
	
  Well Woman Exams

  	
   

  	
  ($300 maximum, included in Annual Routine Exam):

  	
   

  	
   

  
	
  • Office Visit

  	
   

  	
  100% covered (does not apply to deductible)

  	
   

  	
  $15 copay

  
	
  • Mammogram

  	
   

  	
  100% covered (does not apply to deductible)

  	
   

  	
  No charge

  
	
  • Pap Smear

  	
   

  	
  100% covered (does not apply to deductible)

  	
   

  	
  No charge

  
	
  X-ray and Lab Tests

  	
   

  	
  80% after deductible

  	
   

  	
  No charge

  
	
  Emergency Medical Services

  	
   

  	
  Emergency Medical Services

  	
   

  	
  Emergency Medical Services

  
	
  Professional Services (at hospital)

  	
   

  	
  80% after deductible

  	
   

  	
  No charge

  
	
  Hospital Emergency Room

  	
   

  	
  80% after deductible

  	
   

  	
  $50 copay, waived if admitted

  
	
  Maternity

  	
   

  	
  Maternity

  	
   

  	
  Maternity

  
	
  Hospital

  	
   

  	
  80% after deductible

  	
   

  	
  Same as Hospital Services – Inpatient section above

  
	
  Office Visits

  	
   

  	
  80% after deductible

  	
   

  	
  $15 copay

  
	
  Infertility Diagnostic Procedures

  	
   

  	
  80% after deductible

  	
   

  	
  50% (copay will not be applied to out-of-pocket maximum)

  
	
  Mental Health Care/Substance Abuse

  	
   

  	
  Mental Health Care/Substance Abuse

  	
   

  	
  Mental Health Care/Substance Abuse

  
	
  Inpatient

  	
   

  	
  80% after deductible

  (up to 30 days per calendar year)

  	
   

  	
  $100/day copay, up to 30 days per year (copay will not be applied to
  out-of-pocket maximum)

  
	
  Outpatient

  	
   

  	
  80% after deductible

  (50 visit maximum/calendar year)

  	
   

  	
  $35 copay, up to 20 visits per year

  
	
  Miscellaneous Services

  	
   

  	
  Miscellaneous Services

  	
   

  	
  Miscellaneous Services

  
	
  Chiropractic

  	
   

  	
  80% after deductible (26 visit maximum/calendar year)

  	
   

  	
  $15 copay, when approved by PCP

  
	
  Acupuncture

  	
   

  	
  80% after deductible (26 visit maximum/calendar year)

  	
   

  	
  $15 copay, when approved by PCP

  
	
  Physical Therapy/Physical Medicine

  	
   

  	
  80% after deductible

  	
   

  	
  $15 copay, up to 60 visits per year

  
	
  Allergy Test

  	
   

  	
  80% after deductible

  	
   

  	
  $15 copay

  
	
  Allergy Treatment

  	
   

  	
  80% after deductible

  	
   

  	
  $15 copay

  
	
  Prescription Drugs

  	
   

  	
  Prescription Drugs(4)

  	
   

  	
  Prescription Drugs(4)

  
	
   

  	
   

  	
  $7 generic copay; 30-day supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary); 30-day supply

  	
   

  	
  $7 generic copay;  30-day
  supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary); 30-day supply

  
	
   

  	
   

  	
  $14 generic/$30 brand (formulary)

  /$60 brand (non-formulary)

  mail order copay (90-day supply)

  	
   

  	
  $14 generic/$30 brand (formulary)/

  $60 brand (non-formulary)

  mail order copay (90-day supply)

  
	
   

  	
   

  	
  Infertility drugs not covered

  	
   

  	
  Infertility drugs not covered

  
	
  Customer Service Number

  	
   

  	
  (800) 234-0111

  	
   

  	
  (800) 234-0111 or www.bluecrossca.com

  

 

(1)                                  This plan is for associates who live in an
area where neither a PPO network nor an HMO network is available.

 

(2)                                  The deductible is included in the
out-of-pocket maximum.

 

(3)                                  Hospital Services—Pre-certification is
required. You must initiate; failure to do so will result in a $250 additional
deductible for medically necessary care. Under no circumstances are benefits
payable for unnecessary care. No pre-existing
conditions apply.

 

(4)                                  If you choose a brand drug
when a generic is available, you will pay the generic copay plus 100% of the cost difference between
the brand and the generic retail or mail order cost.

 

15

 

	
   

  	
   

  	
  Blue Choice
  Healthcare (GA)

  	
   

  	
  UNICARE HMO
  (IL)

  	
   

  	
  UNICARE
  Health Plan of Texas

  	
   

  
	
  Deductible

  	
   

  	
  Deductible

  	
   

  	
  Deductible

  	
   

  	
  Deductible

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Individual

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  
	
  Family

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  
	
  Out-of-Pocket Maximum

  	
   

  	
  Out-of-Pocket Maximum

  	
   

  	
  Out-of-Pocket Maximum

  	
   

  	
  Out-of-Pocket Maximum

  	
   

  
	
  Individual

  	
   

  	
  None

  	
   

  	
  $ 1,500

  	
   

  	
  $ 1,500

  	
   

  
	
  Family

  	
   

  	
  None

  	
   

  	
  $ 3,000

  	
   

  	
  $ 3,000 (2 family members)

  $ 4,500 (3 or more family members)

  	
   

  
	
  Hospital Services

  	
   

  	
  Hospital Services

  	
   

  	
  Hospital Services

  	
   

  	
  Hospital Services

  	
   

  
	
  Inpatient

  	
   

  	
  $250 room and board copay per admission

  	
   

  	
  $250 room and board copay per admission

  	
   

  	
  $250 room and board copay per admission

  	
   

  
	
  Outpatient

  	
   

  	
  No charge

  	
   

  	
  No charge

  	
   

  	
  No charge

  	
   

  
	
  Skilled Nursing Facility

  	
   

  	
  No charge (up to 30 days per year)

  	
   

  	
  No charge (up to 60 days per year)

  	
   

  	
  No charge (up to 100 days per year)

  	
   

  
	
  Professional Services

  	
   

  	
  Professional Services

  	
   

  	
  Professional Services

  	
   

  	
  Professional Services

  	
   

  
	
  Office Visits

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay 

  	
   

  
	
  Well Baby Care:

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  • Office Visits

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  
	
  • Immunizations

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  No charge

  	
   

  
	
  Annual Routine Exam

  ($300
  maximum, including Well Woman Exam):

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  
	
  Well Woman Exams

  ($300
  maximum, included in Annual Routine Exam):

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  • Office Visit

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  
	
  • Mammogram

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay (if doctor’s office visit)

  	
   

  	
  No charge

  	
   

  
	
  • Pap Smear

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay (if doctor’s office visit)

  	
   

  	
  No charge

  	
   

  
	
  X-ray and Lab Tests

  	
   

  	
  No charge

  	
   

  	
  No charge

  	
   

  	
  No charge

  	
   

  
	
  Emergency Medical Services

  	
   

  	
  Emergency Medical Services

  	
   

  	
  Emergency Medical Services

  	
   

  	
  Emergency Medical Services

  	
   

  
	
  Professional Services (at hospital)

  	
   

  	
  No charge

  	
   

  	
  No charge

  	
   

  	
  No charge

  	
   

  
	
  Hospital Emergency Room

  	
   

  	
  $50 copay, waived if admitted

  	
   

  	
  $50 copay

  	
   

  	
  $50 copay (waived if admitted)

  	
   

  
	
  Maternity

  	
   

  	
  Maternity

  	
   

  	
  Maternity

  	
   

  	
  Maternity

  	
   

  
	
  Hospital

  	
   

  	
  Same as Hospital Services – Inpatient section above

  	
   

  	
  Same as Hospital Services – Inpatient section above

  	
   

  	
  Same as Hospital Services – Inpatient section above

  	
   

  
	
  Office Visits

  	
   

  	
  $15 copay (first visit only)

  	
   

  	
  $15 copay (first visit only)

  	
   

  	
  $15 copay

  	
   

  
	
  Infertility Diagnostic Procedures

  	
   

  	
  $15 copay (artificial insemination and in-vitro fertilization are
  excluded)

  	
   

  	
  No charge (4 attempts for actual infertility per lifetime)

  	
   

  	
  50% (copay will not be applied to out-of-pocket maximum)

  	
   

  
	
  Mental Health Care/Substance Abuse

  	
   

  	
  Mental Health Care/Substance Abuse

  	
   

  	
  Mental Health Care/Substance Abuse

  	
   

  	
  Mental Health Care

  	
   

  
	
  Inpatient

  	
   

  	
  No charge, up to 30 days per year; 6 day limit for substance abuse

  	
   

  	
  No charge, up to 30 days per year

  	
   

  	
  $100/day copay, up to 30 days per year (copay will not be applied to
  out-of-pocket maximum)

  	
   

  
	
  Outpatient

  	
   

  	
  $25 copay, up to 20 visits per year

  	
   

  	
  $20 copay, up to 20 visits per year

  	
   

  	
  $35 copay, up to 20 visits per year when ordered by PCP
  (psychoanalysis excluded)

  	
   

  
	
  Miscellaneous Services

  	
   

  	
  Miscellaneous Services

  	
   

  	
  Miscellaneous Services

  	
   

  	
  Miscellaneous Services

  	
   

  
	
  Chiropractic

  	
   

  	
  Not covered

  	
   

  	
  Not covered

  	
   

  	
  $15 copay, when approved by PCP

  	
   

  
	
  Acupuncture

  	
   

  	
  Not covered

  	
   

  	
  Not covered

  	
   

  	
  $15 copay, when approved by PCP

  	
   

  
	
  Physical Therapy/Physical Medicine

  	
   

  	
  $15 copay, up to 20 visits per year

  	
   

  	
  $15 copay, up to 60 visits per year

  	
   

  	
  $15 copay, up to 60 visits per year

  	
   

  
	
  Allergy Test

  	
   

  	
  $15 copay

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  $15 copay

  	
   

  
	
  Allergy Treatment

  	
   

  	
  $15 copay

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  $15 copay

  	
   

  
	
  Prescription Drugs

  	
   

  	
  Prescription Drugs(4)

  	
   

  	
  Prescription Drugs(4)

  	
   

  	
  Prescription Drugs(4)

  	
   

  
	
   

  	
   

  	
  $7 generic copay; 30-day supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary); 30-day supply

  	
   

  	
  $7 generic copay; 30-day supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary); 30-day supply

  	
   

  	
  $7 generic copay; 30-day supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary); 30-day supply

  	
   

  
	
   

  	
   

  	
  $14 generic/$30 brand (formulary)/$60 brand (non-formulary) mail order
  copay (90-day supply)

  	
   

  	
  $14 generic/$30 brand (formulary)/$60 brand (non-formulary) mail order
  copay (90-day supply)

  	
   

  	
  $14 generic/$30 brand (formulary)/$60 brand (non-formulary) mail order
  copay (90-day supply)

  	
   

  
	
   

  	
   

  	
  Infertility drugs not covered

  	
   

  	
   

  	
   

  	
  Infertility drugs not covered

  	
   

  
	
  Customer Service Number

  	
   

  	
  (800) 441-2273 or www.bcbsga.com

  TDD: (404) 842-8073

  	
   

  	
  (800) 234-0111

  	
   

  	
  (888) 955-4200 or www.unicare.com

  	
   

  

 

 

16

 

	
   

  	
   

  	
  Network
  Blue

  New England (MA)

  	
   

  	
  Blue Care
  Network

  of S.E. Michigan

  	
   

  	
  HMO Blue
  Cross

  (Dallas/Ft. Worth)

  
	
  Deductible

  	
   

  	
  Deductible

  	
   

  	
  Deductible

  	
   

  	
  Deductible

  
	
  Individual

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  	
  There is no deductible; some services require a copay

  
	
  Family

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  	
  There is no deductible; some services require a copay

  
	
  Out-of-Pocket Maximum

  	
   

  	
  Out-of-Pocket Maximum

  	
   

  	
  Out-of-Pocket Maximum

  	
   

  	
  Out-of-Pocket Maximum

  
	
  Individual

  	
   

  	
  None

  	
   

  	
  None

  	
   

  	
  $1,000

  
	
  Family

  	
   

  	
  None

  	
   

  	
  None

  	
   

  	
  $2,000

  
	
  Hospital Services

  	
   

  	
  Hospital Services

  	
   

  	
  Hospital Services

  	
   

  	
  Hospital Services

  
	
  Inpatient

  	
   

  	
  $250 room and board copay per admission

  	
   

  	
  $250 room and board copay per admission

  	
   

  	
  $275 room and board copay per admission

  
	
  Outpatient

  	
   

  	
  $15 copay in office visit setting

  	
   

  	
  No charge

  	
   

  	
  $100 copay for outpatient surgery

  
	
  Skilled Nursing Facility

  	
   

  	
  $250 per admission (up to 100 days per year)

  	
   

  	
  No charge (up to 45 days per year)

  	
   

  	
  $25 copay per day (up to 60 days per year)

  
	
  Professional Services

  	
   

  	
  Professional Services

  	
   

  	
  Professional Services

  	
   

  	
  Professional Services

  
	
  Office Visits

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  
	
  Well Child Care

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  • Office Visits

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  	
  No charge

  
	
  • Immunizations

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  No charge

  
	
  Annual Routine Exam

  ($300
  maximum, including Well Woman Exam):

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  	
  No charge (office visit copay may apply)

  
	
  Well Woman Exams

  ($300
  maximum, included in Annual Routine Exam):

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  • Office Visit

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  
	
  • Mammogram

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  No charge (office visit copay may apply)

  
	
  • Pap Smear

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  No charge (office visit copay may apply)

  
	
  X-ray and Lab Tests

  	
   

  	
  No charge

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  	
  No charge

  
	
  Emergency Medical Services

  	
   

  	
  Emergency Medical Services

  	
   

  	
  Emergency Medical Services

  	
   

  	
  Emergency Medical Services

  
	
  Professional Services (at hospital)

  	
   

  	
  No charge

  	
   

  	
  No charge

  	
   

  	
  No charge

  
	
  Hospital Emergency Room

  	
   

  	
  $50 copay (waived if admitted)

  	
   

  	
  $50 copay

  	
   

  	
  $75 copay ($30 copay for urgent care)

  
	
  Maternity

  	
   

  	
  Maternity

  	
   

  	
  Maternity

  	
   

  	
  Maternity

  
	
  Hospital

  	
   

  	
  Same as Hospital Services – Inpatient section above

  	
   

  	
  Same as Hospital Services – Inpatient section above

  	
   

  	
  Same as Hospital Services – Inpatient section above

  
	
  Office Visits

  	
   

  	
  No charge

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay for first visit only

  
	
  Infertility Diagnostic Procedures

  	
   

  	
  $15 per visit

  	
   

  	
  $15 copay for first visit, then 50% of covered charges

  	
   

  	
  $15 copay for outpatient diagnostic conseling, consultations and
  planning services

  
	
  Mental Health Care/Substance Abuse

  	
   

  	
  Mental Health Care/Substance Abuse

  	
   

  	
  Mental Health Care/Substance Abuse

  	
   

  	
  Mental Health Care

  
	
  Inpatient

  	
   

  	
  Same as Hospital Services – Inpaitient section above, up to 60 days
  per year for mental health care and up to 30 days per year for substance
  abuse

  	
   

  	
  No charge, up to 30 days per year for mental health care and 50% copay
  for detoxification 

  (1 program/year)

  	
   

  	
  Inpatient: 50% of allowable amount, up to 30 days per year

  Outpatient: $25 copay per visit, up to 20 visits per year

  
	
  Outpatient

  	
   

  	
  $15 copay/visit up to 24 visits/year for mental health care and up to
  8 visits/year for substance abuse

  	
   

  	
  50% copay, up to 20 visits per year

  	
   

  	
  Substance Abuse (limited to 3 treatments per lifetime)

  Inpatient: $275 copay per admission

  Outpatient: $15 copay

  
	
  Miscellaneous Services

  	
   

  	
  Miscellaneous Services

  	
   

  	
  Miscellaneous Services

  	
   

  	
  Miscellaneous Services

  
	
  Chiropractic

  	
   

  	
  Not covered

  	
   

  	
  Covered when referred by PCP

  	
   

  	
  $15 copay with PCP referral

  
	
  Acupuncture

  	
   

  	
  Not covered

  	
   

  	
  Not covered

  	
   

  	
  Not covered

  
	
  Physical Therapy/Physical Medicine

  	
   

  	
  $15 copay, up to 60 visits per year

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay with PCP referral

  
	
  Allergy Test

  	
   

  	
  $15 copay

  	
   

  	
  50% copay for testing

  	
   

  	
  50% copay

  
	
  Allergy Treatment

  	
   

  	
  No charge

  	
   

  	
  $5 copay for injections (office visit copay may apply)

  	
   

  	
  50% copay

  
	
  Prescription Drugs

  	
   

  	
  Prescription Drugs

  	
   

  	
  Prescription Drugs

  	
   

  	
  Prescription Drugs

  
	
   

  	
   

  	
  $35 non-preferred/$20 preferred brand/$10 generic copay (at Network
  Blue-participating pharmacies)–30-day supply

  	
   

  	
  $5 generic copay; 30-day supply (retail or mail order)

  $15 brand copay; 30-day supply (retail or mail order)

  	
   

  	
  $10 generic copay; 30-day supply

  $15 brand copay (preferred); 30-day supply

  $30 brand copay (non-preferred); 30-day supply

  
	
   

  	
   

  	
  $70 non-preferred/$40 preferred brand/$20 generic mail order copay –
  90-day supply

  	
   

  	
  $25 brand copay (non-preferred)

  (retail or mail order)

  	
   

  	
  $30/$45/$90 mail order 

  copay—90-day supply

  	 

	
  Customer Service Number

  	
   

  	
  (800) 588-5509 or www.bcbsma.com

  	
   

  	
  (800) 662-6667 or www.bcbsm.com

  	
   

  	
  (877) 299-2377 or www.bcbstx.com

  Group #60611

  

 

17

 

Missouri

 

	
   

  	
   

  	
  HealthLink
  (not available in Sprigfield)

  Alliance (available outside of St. Louis)

  Alliance
  Choice/Preferred (available in the Greater St. Louis Area)

  	
   

  

 

Deductible(1)

 

	
   

  	
   

  	
  250

  	
   

  	
  500

  	
   

  	
  1000

  	
   

  
	
  Individual

  	
   

  	
  $

  	
  250

  	
   

  	
  $

  	
  500

  	
   

  	
  $

  	
  1,000

  	
   

  
	
  Family

  	
   

  	
  $

  	
  750

  	
   

  	
  $

  	
  1,500

  	
   

  	
  $

  	
  3,000

  	
   

  

 

Out-of-Pocket
Maximum(2)

 

	
   

  	
   

  	
  250

  	
   

  	
  500

  	
   

  	
  1000

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Network

  	
   

  	
  Non-Network

  	
   

  	
  Network

  	
   

  	
  Non-Network

  	
   

  	
  Network

  	
   

  	
  Non-Network

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Individual

  	
   

  	
  $

  	
  2,500

  	
   

  	
  $

  	
  6,900

  	
   

  	
  $

  	
  3,500

  	
   

  	
  $

  	
  7,100

  	
   

  	
  $

  	
  4,500

  	
   

  	
  $

  	
  7,600

  	
   

  
	
  Family

  	
   

  	
  $

  	
  7,500

  	
   

  	
  $

  	
  20,700

  	
   

  	
  $

  	
  10,500

  	
   

  	
  $

  	
  21,300

  	
   

  	
  $

  	
  13,500

  	
   

  	
  $

  	
  22,800

  	
   

  

 

	
   

  	
   

  	
  Network
  Providers

  	
   

  	
  Non-Network
  Providers

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Hospital Services(3)

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  	
   

  
	
  Outpatient

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  	
   

  
	
  Skilled Nursing Facility

  	
   

  	
  80% after deductible; limited to 100 days/calendar year

  	
   

  	
  60% after deductible; limited to 100 days/calendar year

  	
   

  
	
  Professional Services

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Office Visits

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% after deductible

  	
   

  
	
   

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
  60% after deductible

  	
   

  
	
   

  	
   

  	
  1000

  	
   

  	
  $30 copay

  	
   

  	
  60% after deductible

  	
   

  
	
  Well Baby Care:

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  • Office Visits

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% after deductible

  	
   

  
	
   

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
  60% after deductible

  	
   

  
	
   

  	
   

  	
  1000

  	
   

  	
  $30 copay

  	
   

  	
  60% after deductible

  	
   

  
	
  • Immunizations

  	
   

  	
   

  	
   

  	
  $0 copay

  	
   

  	
  60% after deductible

  	
   

  
	
  Annual Routine Exam:

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% after deductible

  	
   

  
	
  (Including
  Well Woman Exam)

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
  60% after deductible

  	
   

  
	
  Mammogram
  and Pap Smear

  	
   

  	
  1000

  	
   

  	
  $30 copay

  	
   

  	
  60% after deductible

  	
   

  
	
  X-ray and Lab Tests

  	
   

  	
  Included in copay

  	
   

  	
   

  	
   

  	
  60% after deductible

  	
   

  
	
  Emergency Medical Services

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Professional Services (at hospital)

  	
   

  	
  80% after deductible

  	
   

  	
  80% after deductible

  	
   

  
	
  Hospital Emergency Room

  	
   

  	
  80% after deductible

  	
   

  	
  80% after deductible

  	
   

  
	
  Maternity

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Hospital

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  	
   

  
	
  Office Visits

  	
   

  	
  250

  	
   

  	
  $50 copay, first visit only

  	
   

  	
  60% after deductible

  	
   

  
	
   

  	
   

  	
  500

  	
   

  	
  $50 copay, first visit only

  	
   

  	
  60% after deductible

  	
   

  
	
   

  	
   

  	
  1000

  	
   

  	
  $50 copay, first visit only

  	
   

  	
  60% after deductible

  	
   

  
	
  Infertility Diagnostic Procedures

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  	
   

  
	
  Mental Health Care/Substance Abuse

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Inpatient (up to 30 days per
  calendar year)

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  	
   

  
	
  Outpatient

  	
   

  	
  80% after deductible

  50 visit maximum/calendar year

   

  	
   

  	
  60% after deductible

  50 visit maximum/calendar year

   

  	
   

  
	
  Miscellaneous Services

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Chiropractic (26 visit maximum/calendar
  year)

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% ($25 maximum/visit – after deductible has been met)

  	
   

  
	
   

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1000

  	
   

  	
  $30 copay

  	
   

  	
   

  	
   

  
	
  Physical Therapy/Physical Medicine

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  	
   

  
	
  Allergy Test

  	
   

  	
  250

  	
   

  	
  $20 copay

  	
   

  	
  60% after deductible

  	
   

  
	
   

  	
   

  	
  500

  	
   

  	
  $25 copay

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  1000

  	
   

  	
  $30 copay

  	
   

  	
   

  	
   

  
	
  Allergy Treatment

  	
   

  	
  80% after deductible

  	
   

  	
  60% after deductible

  	
   

  
	
  Prescription Drugs(4)

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  $7 generic copay; 30-day supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary); 30-day supply

  	
   

  	
  $7 generic copay; 30-day supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary); 30-day supply

  	
   

  
	
   

  	
   

  	
  $14 generic/$30 brand (formulary)

  $60 brand (non-formulary)

  mail order copay (90-day supply)

  	
   

  	
  $14 generic/$30 brand (formulary)

  $60 brand (non-formulary)

  mail order copay (90-day supply)

  	
   

  
	
   

  	
   

  	
  Infertility drugs not covered

  	
   

  	
  Infertility drugs not covered

  	
   

  
	
  Customer Service Numbers

  	
   

  	
  Alliance,
  Alliance Choice/Preferred – (800) 556-6769 or www.bcbsmo.com

  HealthLink – (800) 624-2356 or www.healthlink.com

  	
   

  

 

(1)                                  Deductible – Copay amounts do not apply toward
the deductible.

 

(2)                                  Satisfying the smaller in-network coinsurance
and deductible will apply toward, but not satisfy, the larger out-of-network
coinsurance and deductible, excluding any copays. Satisfying the larger
out-of-network coinsurance and deductible will automatically satisfy the
smaller in-network coinsurance and deductible, excluding any copays. Copays do
not apply to the out-of-pocket maximum.

 

(3)                                  Hospital Services – Pre-certification is
required. You must initiate; failure to do so will result in a $250 additional
deductible for medically necessary care. Under no circumstances are benefits
payable for unnecessary care. No pre-existing
conditions apply.

 

(4)                                 If you choose a brand drug
when a generic is available, you will pay the generic copay plus 100% of the cost difference between
the brand and the generic retail or mail order cost.

 

18

 

	
   

  	
   

  	
  BlueCHOICE
  HMO

  (not available in Cape Giradeau)

  	
   

  	
  HealthLink
  HMO

  (not available in Springfield)

  	
   

  
	
  Deductible

  	
   

  	
  Deductible

  	
   

  	
  Deductible

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Individual

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  
	
  Family

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  	
  There is no deductible; some services require a copay

  	
   

  
	
  Out-of-Pocket Maximum

  	
   

  	
  Out-of-Pocket Maximum

  	
   

  	
  Out-of-Pocket Maximum

  	
   

  
	
  Individual

  	
   

  	
  There is no out-of-pocket maximum

  	
   

  	
  There is no out-of-pocket maximum

  	
   

  
	
  Family

  	
   

  	
  There is no out-of-pocket maximum

  	
   

  	
  There is no out-of-pocket maximum

  	
   

  
	
  Hospital Services

  	
   

  	
  Hospital Services

  	
   

  	
  Hospital Services

  	
   

  
	
  Inpatient

  	
   

  	
  $250 room and board copay per admission

  	
   

  	
  $250 room and board copay per admission

  	
   

  
	
  Outpatient

  	
   

  	
  No charge

  	
   

  	
  No charge

  	
   

  
	
  Skilled Nursing Facility

  	
   

  	
  No charge (up to 100 days per year)

  	
   

  	
  No charge (up to 100 days per year)

  	
   

  
	
  Professional Services

  	
   

  	
  Professional Services

  	
   

  	
  Professional Services

  	
   

  
	
  Office Visits

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Well Baby Care:

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  • Office Visits

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  
	
  • Immunizations

  	
   

  	
  $15 copay

  	
   

  	
  No charge (office visit copay may apply)

  	
   

  
	
  Annual Routine Exam:

  (Including
  Well Woman Exam Mammogram and Pap Smear)

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  
	
  X-ray and Lab Tests

  	
   

  	
  No charge

  	
   

  	
  No charge

  	
   

  
	
  Emergency Medical Services

  	
   

  	
  Emergency Medical Services

  	
   

  	
  Emergency Medical Services

  	
   

  
	
  Professional Services (at hospital)

  	
   

  	
  No charge

  	
   

  	
  No charge

  	
   

  
	
  Hospital Emergency Room

  	
   

  	
  $50 copay, waived if admitted

  	
   

  	
  $50 copay, waived if admitted

  	
   

  
	
  Maternity

  	
   

  	
  Maternity

  	
   

  	
  Maternity

  	
   

  
	
  Hospital

  	
   

  	
  Same as Hospital Services – Inpatient section above

  	
   

  	
  Same as Hospital Services – Inpatient section above

  	
   

  
	
  Office Visits

  	
   

  	
  $50 copay, first visit only

  	
   

  	
  $50 copay, first visit only

  	
   

  
	
  Infertility Diagnostic Procedures

  	
   

  	
  50% (copay will not be applied to out-of-pocket maximum)

  	
   

  	
  50% (copay will not be applied to out-of-pocket maximum)

  	
   

  
	
  Mental Health Care/Substance Abuse

  	
   

  	
  Mental Health Care/Substance Abuse

  	
   

  	
  Mental Health Care/Substance Abuse

  	
   

  
	
  Inpatient (up to 30 days per
  calendar year)

  	
   

  	
  $100/day copay, up to 30 days per year

  	
   

  	
  $100/day copay, up to 30 days per year

  	
   

  
	
  Outpatient (50 visit maximum/calendar
  year)

  	
   

  	
  $35 copay, up to 20 visits per year, when ordered by a PCP
  (psychoanalysis excluded)

  	
   

  	
  $35 copay, up to 20 visits per year, when ordered by a PCP
  (psychoanalysis excluded)

  	
   

  
	
  Miscellaneous Services

  	
   

  	
  Miscellaneous Services

  	
   

  	
  Miscellaneous Services

  	
   

  
	
  Chiropractic (26 visit maximum/calendar
  year)

  	
   

  	
  $15 copay when approved by PCP

  	
   

  	
  $15 copay when approved by PCP

  	
   

  
	
  Physical Therapy/Physical Medicine

  	
   

  	
  $15 copay, up to 60 visits per year

  	
   

  	
  $15 copay, up to 60 visits per year

  	
   

  
	
  Allergy Test

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  
	
  Allergy Treatment

  	
   

  	
  $15 copay

  	
   

  	
  $15 copay

  	
   

  
	
  Prescription Drugs(4)

  	
   

  	
  Prescription Drugs

  	
   

  	
  Prescription Drugs

  	
   

  
	
   

  	
   

  	
  $7 generic copay; 30-day supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary);

  30-day supply

  	
   

  	
  $7 generic copay; 30-day supply

  $15 brand copay (formulary); 30-day supply

  $30 brand copay (non-formulary);

  30-day supply

  	
   

  
	
   

  
	
   

  
	
   

  	
   

  	
  $14 generic/$30 brand (formulary)

  $60 brand (non-formulary)

  mail order copay (90-day supply)

  	
   

  	
  $14 generic/$30 brand (formulary)

  $60 brand (non-formulary)

  mail order copay (90-day supply)

  	
   

  
	
   

  	
   

  	
  Infertility drugs not covered

  	
   

  	
  Infertility drugs not covered

  	
   

  
	
  Customer Service Number

  	
   

  	
  (866) 622-8322

  or www.bcbsmo.com

  	
   

  	
  (800) 624-2356

  or www.healthlink.com

  	
   

  

 

19

 

Pre-Certification

 

If you are covered under the PPO or the Group Medical
Plan and need care from a hospital (inpatient only), ambulatory surgical center
(outpatient only), or a chemical dependency rehabilitation facility, you must
obtain a pre-certification. This ensures you obtain the maximum benefits
available under the Plan.

 

You must call for pre-certification three days before your scheduled admission or care.
For an emergency admission, you must call within 48 hours after the start of
the confinement. To obtain a pre-certification, call the toll-free phone number
listed on your ID card. If treatment will be provided by a network physician,
your physician may make the call for you, but you are responsible if this call
does not occur.

 

Notes:

 

•                                          If a
pre-certification is not obtained, an additional deductible of $250 will apply.

 

•                                          The Plan
will not cover services that are not deemed medically necessary.

 

Pre-Existing
Conditions

 

Pre-existing condition
exclusions have been eliminated from the PPO and Group Medical Plans.

 

Reasonable
and Customary Charges

 

The term “reasonable and
customary” applies to the PPO (if you use an out-of-network provider) and Group
Plans. If you are covered by an HMO, please contact the HMO directly for its
definition of reasonable and customary.

 

At the time of service, the
Claims Administrator determines whether or not the charges are reasonable and
customary. Because of the changing nature of medicine, the definition of
reasonable and customary charges may change over time.

 

With the PPO, you have the
choice of receiving care from network providers, who accept lower negotiated
rates, or from non-network providers.

 

2003 Provider Networks

 

	
  State

  	
   

  	
  Vendor(s)

  	
   

  	
  Customer

  Service Number

  	
   

  	
  Internet

  Address

  	
   

  
	
  Connecticut

  	
   

  	
  PHCS, UNICARE New England Classic

  	
   

  	
  (800) 234-0111

  	
   

  	
  www.unicare.com (click on Platinum Network
  Provider Finder)

  	
   

  
	
  Illinois

  	
   

  	
  UNICARE Classic

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Indiana

  	
   

  	
  Sagamore Plus

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Maryland

  	
   

  	
  National Capital PPO

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Massachusetts

  	
   

  	
  UNICARE New England Classic

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Michigan

  	
   

  	
  PPOM

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Minnesota

  	
   

  	
  Preferred One

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  New Hampshire

  	
   

  	
  UNICARE New England Classic

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  New Jersey

  	
   

  	
  Tristate (formerly Latitude)—QualCare

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  New York (south)

  	
   

  	
  Tristate (formerly Latitude)—Multiplan

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  North Carolina

  	
   

  	
  MedCost Preferred

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Ohio

  	
   

  	
  UNICARE Classic Network

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Oklahoma

  	
   

  	
  PPO Oklahoma

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Texas

  	
   

  	
  UNICARE Classic Network

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Virginia (northern)

  	
   

  	
  National Capital PPO

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Washington D.C.

  	
   

  	
  National Capital PPO

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  California

  	
   

  	
  Prudent Buyer

  	
   

  	
  (800) 234-0111

  	
   

  	
  www.bluecrossca.com

  	
   

  
	
  Georgia

  	
   

  	
  BlueCare

  	
   

  	
  (800) 441-2273

  	
   

  	
  www.bcbsga.com

  	
   

  
	
  Missouri

  	
   

  	
  Alliance, Alliance Choice, Alliance Preferred

  	
   

  	
  (800) 556-6769

  	
   

  	
  www.bcbsmo.com

  	
   

  
	
  Missouri (St. Louis only)

  	
   

  	
  HealthLink—St. Louis

  	
   

  	
  (800) 624-2356

  	
   

  	
  www.healthlink.com

  	
   

  

 

20

 

Medically Necessary

 

The PPO and Group Plans cover expenses deemed “medically necessary.”
Medically necessary services or supplies must meet certain requirements
established by the Claims Administrator. The fact that a doctor may prescribe,
order, recommend or approve a service or supply does not, of itself, make it
“medically necessary” or make the charge a covered expense, even if it has not
been listed as an exclusion.

 

Additional Information About HMO Coverage

 

Coverage When Traveling

 

As a member of a Blue Cross/Blue Shield HMO, you and your enrolled
dependents are eligible for Away From Home Care benefits. These benefits cover
urgent care, those not so serious illnesses that need medical attention, for
you and your enrolled family members when traveling outside your HMO service
area.

 

To access Away From Home Care, call the toll-free number printed on
your ID card.

 

Coverage for Temporary
Residency
Outside of California

 

You can maintain your HMO benefits even when temporarily residing
outside California with Guest Membership. It’s available to long-term travelers
for out-of-state work assignments, students and other enrolled family members
who will be living away from home for three to six months.

 

To apply for Guest Membership, call Blue Cross HMO Customer Service to
discuss your changing circumstances. If a participating HMO is available, you
or your dependent will become a guest member of that HMO.

 

Additional Information About All FlexPoint Medical Options

 

Non-Duplication of Benefits

 

If you have coverage under more than one group medical plan, benefits
under the plans will not be duplicated. The primary plan will pay its full
benefits first. The secondary plan will make additional payments, if any are
due, up to the amount it would have paid if it were the primary plan.

 

Binding Arbitration

 

Any dispute between you and the Claims Administrator will be resolved
by binding arbitration and not by lawsuit or resort to court process, except as
applicable state laws provide for judicial review of arbitration proceedings or
where otherwise prohibited by law.

 

Questions?

 

If you have specific benefit questions, please call the Customer
Service number listed in the Medical Comparison Chart.

 

Your local Human Resources office can provide you with HMO or PPO
directories. HMO or PPO directories can also be found on WorkSite.

 

HMOs and Domestic Partner Coverage

 

	
  Blue Cross HMO

  	
   

  	
  Domestic Partner Coverage Allowed

  
	
  UNICARE HMO (IL)

  	
   

  	
  Domestic Partner Coverage Allowed

  
	
  Blue Choice Healthcare (GA)

  	
   

  	
  Domestic Partner Coverage Allowed

  
	
  Network Blue (MA)

  	
   

  	
  Domestic Partner Coverage Allowed

  
	
  Blue Care Network of S.E. Michigan

  	
   

  	
  Same Sex Domestic Partner Coverage Allowed

  
	
  HMO Blue Cross (Dallas/Ft. Worth)

  	
   

  	
  Domestic Partner Coverage Allowed

  
	
  BlueCHOICE HMO (MO)

  	
   

  	
  Domestic Partner Coverage Allowed

  
	
  HealthLink HMO (MO)

  	
   

  	
  Domestic Partner Coverage Allowed

  
	
  UNICARE Health Plan of Texas HMO

  	
   

  	
  Domestic Partner Coverage Allowed

  

 

21

 

Your Dental Coverage

 

FlexPoint gives you a choice of dental options. In making your choice,
consider how much you can afford to pay out of your own pocket toward dental
expenses. Also, are there any procedures you know you or a family member will
need in the upcoming year? Is orthodontic coverage necessary?

 

The information in this Enrollment Guide is only a summary—refer to
your Summary Plan Description for more information.

 

If You Live in California...

 

You may choose Dental Net, the WellPoint
Standard Dental Plan or the WellPoint Enhanced Dental Plan. You also have the
option to waive dental coverage.

 

Dental
Net Plan

 

If you elect this option, you receive care at
negotiated rates. There are no deductibles or annual maximums unless you visit
a Dental Net pediatric dentist. Orthodontic coverage is included.

 

When you enroll in Dental Net, you and each
covered dependent must select your own participating dental office. If you do
not use a Dental Net provider, your dental services will not be covered. Dental
Net provider directories are available on WorkSite or from your local Human
Resources office. The first time you need care, let your dentist know that
you’re a member of Dental Net. If you are newly enrolling in Dental Net or
adding a new dependent, you must complete an HMO and Dental Net enrollment
form. You may change your Dental Net provider by calling the Dental Net
Customer Service number listed in the Dental Comparison Chart.

 

If you are currently receiving treatment for
orthodontia, you cannot change to the WellPoint Enhanced Dental Plan to
continue that treatment. You must be enrolled in the Enhanced Dental Plan at
the beginning of orthodontic treatment for any expenses to be covered under
this plan.

 

If You Live Outside of California...

 

You can choose the WellPoint Standard Dental Plan or WellPoint Enhanced
Dental Plan. You also have the option to waive dental coverage.

 

WellPoint Standard and Enhanced Dental Plans

 

The WellPoint Standard and Enhanced Dental Plans give you the choice to
select virtually any licensed dentist, but if you choose a PPO participating
dentist, you take advantage of negotiated discounts. If you use a dentist who does
not participate in the National Dental PPO plan network, you may pay more for
dental care. For non-network providers, the maximum covered expense is the
reasonable and customary (R&C) charge. You will be responsible for any
billed charges that exceed R&C. If you use a network provider, the maximum
covered expense is the negotiated rate. Network providers will not bill you
more than the negotiated rate. Orthodontic coverage is available under the
Enhanced Dental Plan.

 

Associates can benefit from the addition of a national PPO dental
network. UNICARE dental provider listings are available on WorkSite and at your
local Human Resources office.

 

22

 

Claims Procedures

 

If you use a Dental Net or PPO network provider, your provider will file claims for you and
your covered dependents.

 

If you use a non-network provider, you may be required to complete a dental
claim form and mail it to WellPoint, P.O. Box 9066, Oxnard, California
93031-9066.

 

Questions?

 

If you have specific benefit questions you may call the Customer
Service number listed in the Dental Comparison Chart below.

 

Your local Human Resources office can provide you with Dental Net or
Dental PPO directories. Dental Net or Dental PPO directories can also be found
on WorkSite.

 

Dental Comparison Chart

 

	
   

  	
   

  	
  In
  California

  	
   

  	
  National
  (including California)

  
	
   

  	
   

  	
  Dental Net

  	
   

  	
  Standard Plan(1)

  	
   

  	
  Enhanced Plan(1)

  
	
  Annual Deductible

  	
   

  	
  None

  	
   

  	
  $50/individual

  $150/family

  	
   

  	
  $50/individual

  $150/family

  
	
  Annual Maximum

  	
   

  	
  $500/child for pediatric dentist only

  	
   

  	
  $1,000/individual

  	
   

  	
  $2,000/individual

  
	
  Diagnostic/

  Preventive Care

  	
   

  	
  100%

  	
   

  	
  100% of covered expenses

  	
   

  	
  100% of covered expenses

  
	
  Oral Surgery

  	
   

  	
  100%

  	
   

  	
  80% after deductible

  	
   

  	
  80% after deductible

  
	
  Restorative Care (such as fillings)

  	
   

  	
  100%

  	
   

  	
  80% after deductible

  	
   

  	
  80% after deductible

  
	
  Extractions

  	
   

  	
  100%

  	
   

  	
  80% after deductible

  	
   

  	
  80% after deductible

  
	
  Surgical Extractions

  	
   

  	
  $25—$50 copay

  	
   

  	
  80% after deductible

  	
   

  	
  80% after deductible

  
	
  Endodontic Care (such as root canals)

  	
   

  	
  $60—$100 copay

  	
   

  	
  80% after deductible

  	
   

  	
  80% after deductible

  
	
  Periodontics (such as scaling)

  	
   

  	
  $9—$120 copay

  	
   

  	
  80% after deductible

  	
   

  	
  80% after deductible

  
	
  Crowns

  	
   

  	
  $85—$120 copay

  	
   

  	
  Not covered

  	
   

  	
  50% after deductible

  
	
  Bridges

  	
   

  	
  $120 copay

  	
   

  	
  Not covered

  	
   

  	
  50% after deductible

  
	
  Partial Dentures

  	
   

  	
  $160 copay

  	
   

  	
  Not covered

  	
   

  	
  50% after deductible

  
	
  Complete Dentures

  	
   

  	
  $140 copay

  	
   

  	
  Not covered

  	
   

  	
  50% after deductible

  
	
  Orthodontia

  	
   

  	
  $1,850 copay for adults (age 18+) or $1,450 for children; treatment
  limited to 24 months(2)

  	
   

  	
  Not covered

  	
   

  	
  50% with a $1,250 lifetime benefit/ individual

  
	
  Customer Service

  	
   

  	
  (800) 627-0004

  	
   

  	
  (800) 627-0004

  	
   

  	
  (800) 627-0004

  
	
  Associates in Georgia (ID Cards)

  	
   

  	
   

  	
   

  	
  (800) 441-2273

  	
   

  	
  (800) 441-2273

  
	
  Associates in Missouri

  	
   

  	
   

  	
   

  	
  (800) 556-6769

  	
   

  	
  (800) 556-6769

  

 

Note: Covered expenses are paid based on reasonable and customary
charges. Charges in excess of reasonable and customary are your responsibility.

 

(1)                                  If your dental provider anticipates the
expense for any course of treatment to exceed $350, you should submit a benefit
estimation form before treatment begins. This excludes Dental Net.

 

(2)                                  You must obtain a written referral from Dental
Net Customer Service before receiving treatment. Dental Net will not accept
patients who are “banded” prior to the effective date of coverage. Extra fees
may be charged for X-rays, models, retention, etc. over and above the copay.

 

23

 

Your Vision Coverage

 

If you elect vision coverage, you have a choice of network or
non-network providers each time you need eye care services or products. Vision
coverage is optional. In making your election, think about how much you can
afford to pay out of pocket for vision expenses in the coming year. Also
consider whether you or a family member will need eyeglasses or contacts in the
coming year.

 

Keep in mind that vision coverage is designed
to cover medically necessary eye care. As a result, there are extra charges for
the following:

 

•                                          Blended lenses

 

•                                          Oversize lenses

 

•                                          Photochromatic or tinted lenses

 

•                                          Frames that exceed the Plan allowance (plan
provides a 20% discount on any amount over your allowance)

 

Annual supplies of popular contact lenses are available to you at
competitive prices. Visit www.vsp.com or ask your VSP doctor for
details. Your plan also includes a 15% discount off the cost of your contact
lens exam (fitting and evaluation) when obtained from a VSP doctor. This exam
is performed in addition to your routine eye exam.

 

The plan also provides a 20% discount on additional pairs of
prescription glasses (lenses and frames), including prescription sunglasses, if
you use the same VSP provider.

 

Claims Procedures

 

•                                          If you use a VSP provider, he/she will
confirm your eligibility and file claims for you and your covered dependents.

 

•                                          If you use non-VSP providers, file a claim
with VSP to receive your benefits. Claims should be mailed to: Vision Service
Plan, Attn: Out-of-Network Provider Claims, P.O. Box 997105, Sacramento,
California 95899-7105. You will be responsible for paying any charges above the
limits shown in the chart below.

 

To obtain a list of VSP providers in your area, call(800) 877-7195 or
visit www.vsp.com. You can also access the VSP web page via WorkSite at home.wellpoint.com/ehr/index.asp.

 

Questions?

 

If you have any questions about your vision coverage, call VSP at (800)
877-7195.

 

Your Vision Benefits at a Glance—VSP(1),(2)

 

	
   

  	
   

  	
  VSP
  Providers

  	
   

  	
  Non-VSP
  Providers

  
	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your annual copayment

  	
   

  	
  $25

  	
   

  	
  $25

  
	
  What the Plan Pays

  	
   

  	
   

  	
   

  	
   

  
	
  Eye examinations 

  (once every
  12 months)

  	
   

  	
  100% after copay

  	
   

  	
  $40 maximum

  
	
  Lenses  (once every 12 months)(3)

  	
   

  	
   

  	
   

  	
   

  
	
  • Single

  	
   

  	
  100% after copay

  	
   

  	
  $40 maximum

  
	
  • Bifocal

  	
   

  	
  100% after copay

  	
   

  	
  $60 maximum

  
	
  • Trifocal

  	
   

  	
  100% after copay

  	
   

  	
  $80 maximum

  
	
  • Lenticular

  	
   

  	
  100% after copay

  	
   

  	
  $125 maximum

  
	
  Frames  (once every 24 months)(3)

  	
   

  	
  100% up to a determined
  maximum

  	
   

  	
  $45 maximum

  
	
  Contacts  (including disposables)

  	
   

  	
   

  	
   

  	
   

  
	
  • If medically necessary

  	
   

  	
  100% with prior approval

  	
   

  	
  up to $210, in lieu of
  other benefits

  
	
  • If elective

  	
   

  	
  up to $105, in lieu of
  other benefits

  	
   

  	
  up to $105, in lieu of
  other benefits

  

 

(1)                                  VSP members have access to the Laser
VisionCare Program, in which laser vision correction is available at a
discounted fee. To learn more visit VSP’s Laser VisionCare Program at www.vsp.com/lvc/html/index.htm.

 

(2)                                  You must pay your annual copayment the first
time you receive services whether you use a VSP or non-VSP provider.

 

(3)                                  You and your family may select either one pair
of glasses or contact lenses in a calendar year.

 

24

 

Your Life Insurance Coverage

 

This section describes the coverage available to you under the FlexPoint life insurance plan.

 

As an Officer of WellPoint, you receive life insurance under the Group
Universal Life policy (see FlexExec
on page 32). You should consider your level of FlexPoint
life insurance coverage in light of the Group Universal Life coverage you
receive as an Officer.

 

Benefit Salary

 

Benefits are based on your benefit salary, which is
your annual base pay as of September 1, 2002 plus commissions or sales
incentives paid from September 1, 2001 through August 31, 2002. For Officers
hired on or after September 1, 2002, your benefit salary is your annual base
pay excluding any commissions. Your benefit salary does not change mid-year
with salary increases or changes to your work schedule (part-time to
full-time). It will be recalculated on September 1, 2003 for an effective date
of January 1, 2004.

 

In choosing your coverage level, consider your family status. If you
have dependents and/or a home mortgage, do you need more insurance? What
sources of income would your survivor have if you died?

 

The information in this Enrollment Guide is only a summary—refer to
your Summary Plan Description for more information.

 

Life insurance benefits are rounded to the next higher multiple of
$1,000 unless your salary is an even multiple of $1,000. For example, if your
benefit salary is $89,300 and you elect one times your benefit salary, your
coverage would be rounded up to $90,000. The maximum amount of your coverage cannot exceed $1,000,000.

 

Your benefit is reduced when you reach age 70 and again at age 75. If
you become totally disabled prior to age 60, you will need to apply for a
premium waiver. If approved, no premium payments will be required during this
period of disability.

 

You can choose from the following six life insurance options:

 

•                  $50,000

 

•                  1
times your benefit salary (WellPoint provides this level of coverage at no cost to
you.)

 

•                  2
times your benefit salary 

 

•                  3
times your benefit salary

 

•                  4
times your benefit salary

 

•                  Waive
coverage

 

If you are on a leave of absence on January 1, 2003 and you elect to
increase life coverage for 2003, that new coverage level will not take effect
until you return from the leave and an Evidence of Insurability has been
approved (if applicable).

 

We offer life insurance coverage when you first become eligible without
an Evidence of Insurability form. Increasing your life insurance amount by more
than one level during Open Enrollment requires an Evidence of Insurability form
and is subject to approval by the Claims Administrator.

 

25

 

If, during Open Enrollment, you select a life insurance option that is
two levels greater than your existing coverage, you will need to provide an
Evidence of Insurability form. If approved, your increase in coverage and
deductions will take effect on January 1, 2003 or the first of the month after
insurance company approval is received, whichever is later.

 

If your request is denied, your 2002 level of coverage will increase
only one level for 2003 with the corresponding 2003 cost.

 

Life insurance greater than one times your benefit salary can be
purchased only on an after-tax basis.

 

Life insurance coverage is a fully insured plan administered by BC Life
& Health Insurance Company.

 

Imputed Income

 

The IRS Code states that employee group term life insurance benefits in
excess of $50,000 and dependent life insurance may result in taxable income to
the associate. This is known as “imputed income.” Imputed income must be
reported on your W-2 and is included as earnings in your paycheck. Imputed
income is subject to federal, state and FICA taxes.

 

26

 

Your Dependent Life Insurance Coverage

 

Dependent life insurance enables you to insure the lives of your
spouse/domestic partner and eligible dependent child(ren).

 

If, during Open Enrollment, you add or increase your dependents’
coverage, your dependents may need to complete an Evidence of Insurability
form. When approved, the increase in coverage and deductions will take effect
on January 1 or the first of the month after insurance company approval is
received, whichever is later.

 

For spouse/domestic partner coverage, if your request is denied, the
current level of coverage will remain in effect for2003 with the corresponding
2003 costs. For child life coverage, if your request is denied, your 2002 level
of coverage will increase only one level for 2003, with the corresponding 2003
cost.

 

If you are on a leave of absence on January 1, 2003 and you elect to
increase dependent life insurance for 2003, the new coverage level will not
take effect until you return from the leave and an Evidence of Insurability has
been approved.

 

The information in this Enrollment Guide is only a summary—refer to
your Summary Plan Description for more information.

 

Spouse/Domestic Partner Life Insurance

 

Spouse/domestic partner life insurance is based on your benefit salary
(see page 25 for a definition of benefit salary), and the cost is based on your
age as of January 1, 2003. Benefits are paid directly to you. This
coverage cannot exceed the lesser of 50% of your life insurance amount or
$125,000. Spouse/domestic partner coverage will be reduced when your life
insurance is reduced—at age 70 and again at 75.

 

Spouse/domestic partner life insurance benefits are rounded down to a
multiple of $1,000. For example, if your benefit salary is $89,300 and you
elect spouse life of one times your benefit salary, your spouse’s/domestic
partner’s coverage would be rounded down to $89,000.

 

You may choose from the following options for spouse/domestic partner
life insurance:

 

•                  $5,000

 

•                  1/2
times your benefit salary

 

•                  1
times your benefit salary

 

•                  Waive
coverage

 

Child Life Insurance

 

Child life insurance is a fixed amount depending on the age of your
child(ren).

 

You have the following options for child life insurance, or you can
waive coverage:

 

	
  For Each
  Dependent Child

  	
   

  	
  Option 1

  (1 unit)

  	
   

  	
  Option 2

  (2 units)

  	
   

  	
  Option 3

  (5 units)

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Birth to age 14 days

  	
   

  	
  $

  	
  500

  	
   

  	
  $

  	
  1,000

  	
   

  	
  $

  	
  2,500

  	
   

  
	
  14 days to six months of
  age

  	
   

  	
  $

  	
  2,500

  	
   

  	
  $

  	
  5,000

  	
   

  	
  $

  	
  12,500

  	
   

  
	
  6 months through age 18
  years of age (24 if full-time student)

  	
   

  	
  $

  	
  5,000

  	
   

  	
  $

  	
  10,000

  	
   

  	
  $

  	
  25,000

  	
   

  

 

As with spouse/domestic partner life insurance, benefits are paid to
you, and this coverage cannot exceed 50% of your life insurance amount. All of
your eligible children and your domestic partner’s children may be covered if
you choose this benefit. If you do not enroll a child in child life, that child
will not be covered.

 

You must notify the Associate Service Center when dependents no longer
qualify for coverage (e.g., an ex-spouse after a divorce) or when they reach
the limiting age of 19 (or 25 if a full-time student).

 

If both you and your spouse/domestic partner, or you
and your child/parent, are employed at WellPoint, you may not elect multiple
coverage under the same plans.  For example, you cannot elect spouse/
domestic partner life coverage if your spouse/domestic partner works for
WellPoint.

 

27

 

Your Accidental Death and Dismemberment (AD&D)
Coverage

 

Accidental death and dismemberment (AD&D) coverage protects you if
you die or are seriously dismembered as the result of an accident. The plan
does not pay benefits if you die from natural causes. This benefit is designed
to supplement your life insurance coverage and is a separate election. AD&D
coverage is not available for dependents.

 

The information in this enrollment Guide is
only a summary—refer to your Certificate of Insurance for more information.

 

AD&D benefits are rounded to the next higher multiple of $1,000
unless your benefit salary is an even multiple of $1,000. For example, if your
benefit salary is $89,300 and you elect one times your benefit salary, your
coverage would be rounded up to $90,000.

 

You can choose from the following AD&D options (see page 25 for a
definition of benefit salary):

 

•                  1
times your benefit salary (WellPoint provides this level of coverage at no cost to
you.)

 

•                  2
times your benefit salary

 

•                  3
times your benefit salary

 

•                  4
times your benefit salary

 

The maximum amount of AD&D coverage cannot exceed $1,000,000. You
cannot waive AD&D coverage. You do not need to submit an Evidence of
Insurability form if you increase your level of coverage during Open
Enrollment.

 

The AD&D plan pays the full benefit amount to your beneficiary if
you die as the result of an accident. Your beneficiary will be the same as
listed on your life insurance beneficiary form. The plan pays the full amount
or a percentage of the full amount if you suffer a dismemberment as the result
of an accident. The percentages vary by the seriousness of the injury—refer to
the Certificate of Insurance.

 

If you are on a leave of absence on January 1, 2003, and you elect to
increase AD&D coverage for 2003, the new coverage level will not take
effect until you return from leave.

 

28

 

Your Flexible Spending Accounts

 

Flexible Spending Accounts provide an opportunity for you to save money
on your out-of-pocket health care or dependent daycare expenses throughout the
year. You are not taxed on the money you contribute, nor on the reimbursements
you receive.

 

Tax Savings

 

For most associates who elect flexible spending
accounts, the tax savings are as much as 35 cents on the dollar—28 cents in
federal income tax, 7.65 cents in Social Security and Medicare taxes, plus any
applicable state or local income tax. Your tax savings will be based on your
actual tax circumstances.

 

How Flexible Spending Accounts Work

 

You elect an annual amount of money to be deducted from your biweekly
paychecks on a pretax basis. Based on your annual election, a prorated amount
is subtracted from your paycheck each pay period. When you have an eligible
expense, you file a claim and are reimbursed without paying taxes on this
amount.

 

The full annual amount you elect to defer under the Health Care
Spending Account is available on the effective date of your coverage. So, if
you elect $1,000 for the year and have an eligible expense of $900 in January,
you will be reimbursed the full $900 even though you have only accumulated
$38.46 thus far. Contributions, however, will continue to be deducted for the
remainder of the year. Under the Dependent Day Care Spending Account, you can
be reimbursed only for the amount actually in your account at the time you
submit the claim.

 

The amount you elect to contribute to your accounts over the course of
the year is irrevocable. Once you make your election, you must continue to
contribute at that amount until the end of the calendar year, or you experience
a qualified mid-year change, or termination of employment.

 

Your Health Care Spending Account

 

If you choose to participate, you decide how
much to deposit in the Health Care Spending Account to pay for expenses for you
and your dependents that are not covered by your medical, dental, and vision
plans. For example, health plan deductibles and copayments, mileage and parking
expenses while you’re receiving health care, and contact lens solution are
normally not reimbursed by your insurance plan. But they may be eligible for
reimbursement under a Health Care Spending Account.

 

Some additional examples of eligible expenses
are:

 

•                  Uninsured
medical, dental, vision, and prescription drug expenses and copays

 

•                  Chiropractic
expenses

 

•                  Hearing
aids and batteries

 

•                  Mental
health expenses

 

•                  Prescription
glasses and sunglasses

 

•                  Orthodontia
expenses

 

For a complete list of expenses eligible for
reimbursement, please contact UniAccount at (888) 209-7976.

 

You have through March 31, 2004 to file
Health Care Spending Account claims for expenses incurred on or before December
31, 2003. If you terminate employment prior to December 31, 2003, your claims
must be for expenses incurred on or before your termination with WellPoint.

 

Please note that you are eligible for
reimbursement of domestic partner expenses only if your domestic partner (or
child of the domestic partner) is your dependent for IRS purposes.

 

29

 

How Much Can I Elect?

 

	
   

  	
   

  	
  Minimum

  	
   

  	
  Maximum

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  Pay

  Period

  	
   

  	
  Annually

  	
   

  	
  Pay

  Period

  	
   

  	
  Annually

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Health Care Account

  	
   

  	
  $

  	
  10

  	
   

  	
  $

  	
  260

  	
   

  	
  $

  	
  192.31

  	
   

  	
  $

  	
  5,000

  	
   

  
	
  Dependent Day Care
  Account(1)

  	
   

  	
  $

  	
  10

  	
   

  	
  $

  	
  260

  	
   

  	
  $

  	
  192.31

  	
   

  	
  $

  	
  5,000

  	
   

  

 

(1)                                  Married associates filing a separate tax return can only elect $2,500
per year. Married associates filing a joint return
have a combined maximum of $5,000 per year from all available plans.

 

For purposes of this section, “deductions” are salary
reductions used to pay an equivalent amount of your eligible health care and/or
dependent daycare expenses. Additionally, although this section refers to “your
accounts,” all the deductions are held as part of the general assets of the
Company.

 

You can participate in the Health Care Spending Account even if you
waive medical coverage. Once you enroll in a spending account, you cannot
change your election or contributions for the remainder of that calendar year.
The only exception is if you have a qualified mid-year change (such as the
birth of a child). Refer to the Mid-Year Changes section of this Enrollment
Guide for more details.

 

As you consider participating in the Health Care Spending Account,
think about the following:

 

•                  Do
you anticipate any expenses not covered by your (or your spouse’s) medical,
dental, or vision care plans?

 

•                  Do you anticipate any large out-of-pocket
expenses such as orthodontics, crowns, hearing aids, or the birth of a baby? Do
you need eyeglasses, contact lenses, and/or prescription sunglasses?

 

Your Dependent Day Care Spending Account

 

You can participate in this account if you need dependent daycare
services to enable you to work or, if you are married, for both you and your
spouse/domestic partner (if also your dependent) to work. A dependent must be
under age 13 or a spouse/domestic partner, child or parent that is physically
or mentally incapable of caring for himself or herself and spends at least
eight hours per day in your home.

 

If your spouse/domestic partner (if also your dependent) does not work,
your dependent daycare expenses may be reimbursable if your spouse/domestic
partner is a full-time student or physically or mentally unable to provide care
for himself or herself.

 

In general, any expense that qualifies for the Federal Dependent Care
Tax Credit may be reimbursed. When filing your dependent daycare claims, you
will need to submit the Tax Payer Identification Number or Social Security
Number of the person or entity who provides care. You cannot participate in a
Dependent Day Care Spending Account and file for a Federal Dependent Care Tax
Credit. You may want to consult a tax professional to determine which option is
better for you.

 

This account is for reimbursement of child/elder daycare expenses.  It does
not provide reimbursement for medical expenses of a spouse/domestic partner or
dependent (see “Your Health Care Spending Account” above).

 

Note:  According to IRS
regulations, deductions by highly compensated associates may be subject to
limitations. You will be notified if you are affected by these limitations.

 

As you consider participating in the Dependent Day Care Spending
Account, think about the following:

 

•                  Will
you incur expenses from a licensed daycare center or nursery school?

 

•                  Will
your child(ren) attend an eligible daytime summer camp or before-school or
after-school activities?

 

•                  Would
you save more money from the Federal Dependent Care Tax Credit?

 

•                  Do
you have an aging dependent parent who may require care?

 

30

 

“Use It or Lose It” Rule

 

Under this rule, you must use the money in your Health
Care and/or Dependent Day Care Account for eligible expenses you incur during
the year in which the contributions are made.

 

You have until March 31 of the
following year to request your reimbursement. If you terminate during the
year, you can request reimbursement of the balance in your Dependent Day Care
Account after you terminate if you incur an eligible expense any time during the calendar year, up to the amount you had
withheld from your paycheck. Under the Health Care Account, if you
terminate, you can only request reimbursement for expenses incurred through
your termination date. See the
COBRA section for participation and continuing contributions.

 

If you have a balance left in your Flexible Spending
Accounts after the deadline for requesting reimbursement, the IRS requires it
to be forfeited. Any forfeited amounts are applied to the administration of the
Flexible Spending Accounts.

 

How to File a Claim

 

Health Care Spending Account

 

If you are covered under the PPO or Group Medical Plans, or Standard or
Enhanced Dental Plans, expenses which are only partially covered by your
plan(s) are automatically processed
under your Health Care Flexible Spending Account.

 

You must submit an FSA claim form for unreimbursed expenses if you do
not elect medical and/or dental coverage from WellPoint and for unreimbursed
expenses from an HMO or vision care provider (be sure to include an itemized
statement from the provider of services or an explanation of benefits form).

 

Dependent Day Care Spending Account

 

To obtain reimbursement for qualifying dependent daycare expenses, you
must submit an FSA claim form (be sure to include an itemized statement from
the provider of services and tax identification number—you cannot substitute a
cancelled check for a statement from the provider).

 

Claim Form

 

After you enroll, claim forms will be mailed to you. However, if you
wish, you may obtain a claim form by calling (888) 209-7976 or from WorkSite.

 

Mail
claims to:                   UniAccount

P.O. Box 4381

Woodland Hills, CA 91365-4381

 

Fax claims to:                         (818) 234-4730

 

Reimbursements are mailed to your home 7-10 business days after we
receive the necessary paperwork for your claim.

 

You may view your UniAccount Flexible Spending Account balances and
payment history via the Internet using the Blue Cross of California Member
Services website. You may obtain a personal identification number for direct
access at the site (www.bluecrossca.com/memberservices/).

 

Questions

 

If you have questions about enrolling in a Flexible Spending Account,
contact the Associate Service Center. If you have questions about filing a
claim or reimbursements, please contact UniAccount directly at (888) 209-7976
or by e-mail at UNIACCOUNT.FSA@WellPoint.com.

 

31

 

FlexExec

 

WellPoint provides a number
of benefit programs for its Officers. The following information briefly
outlines your WellPoint benefits. The legal plan documents prevail in any
conflict of interpretation, and the Company reserves the right to modify or
terminate the programs at any time without notice.

 

In addition to the FlexPoint
benefits, the Company provides the following benefits to Officers:

 

•                  Officer
Physical Exams

 

•                  Group
Universal Life Insurance

 

•                  Short-Term
Disability

 

•                  Long-Term
Disability

 

•                  Comprehensive
Executive Non-Qualified Retirement Plan

 

To enroll in the Comprehensive Executive Non-Qualified Retirement Plan,
you need to complete the FlexExec
enrollment form and return it to Steve Selby in the WellPoint Compensation
Department at 4553 La Tienda Drive, Thousand Oaks, CA 91362, Mail Stop T1-1C7.

 

Officer Physical Exams

 

In addition to your medical options under FlexPoint, Vice Presidents and above with at
least one year of service participate in the Officer Physical Exam Program.

 

You are eligible to receive a physical exam at no cost to you according
to this schedule:

 

	
  Your Age

  	
   

  	
  How Often You Can Have a Physical Exam*

  
	
   

  	
   

  	
   

  
	
  44 and younger

  	
   

  	
  Every 24 months

  
	
  45 and older

  	
   

  	
  Every 12 months

  

 

*  Any exceptions to this
schedule must be recommended by a physician and approved by the Company.

 

WellPoint recommends medical centers for the physical exams:

 

•                  Cedars-Sinai
Medical Center Executive Medical Services in Los Angeles

 

•                  Scripps
Center for Executive Health in La Jolla

 

Both facilities offer a comprehensive one-day program. The findings of
your exam will remain confidential between you and your physician.

 

To make an appointment, call the medical center of your choice:

 

	
  Cedars-Sinai Executive

  	
   

  
	
  Medical Services

  	
  (310) 423-2374

  
	
   

  	
   

  
	
  Scripps Center for

  	
   

  
	
  Executive Health

  	
  (858) 626-4460

  

 

Group Universal Life Insurance

 

In addition to your life
insurance options under FlexPoint,
the Company provides you with a supplemental life insurance benefit based upon
your total compensation (September 1, 2002 base annual salary plus target
management bonus).

 

How do I enroll in this coverage?

 

All current Officers who have completed an application for this coverage
in the past are automatically covered. If the amount of coverage increases by
more than 10% from the prior year due to an increase in total compensation, the
insurance company may require an Officer to go through medical underwriting for
the amount over 10% before providing the full coverage increase.

 

32

 

Newly-hired Officers will receive an application in the mail from
Clarke Bardes Consulting/CRG. Coverage will not take effect until the first of
the month following receipt and acceptance of the application by the carrier.

 

How does Universal Life Insurance work?

 

In addition to receiving a fixed life insurance benefit, you also have
the opportunity to make additional premium payments to increase the amount of
your insurance and/or make investments with the earnings accumulating on a
tax-deferred basis.

 

What is the cost of this benefit?

 

The Company pays the entire cost of this life insurance benefit. Your
only cost will be the income tax on the premium paid for the coverage.

 

What happens at termination?

 

You will receive an individual policy, which can be continued by paying
the premium contributions or surrendered for the cash value, if any.

 

Who do I contact for additional information?

 

Contact Rick Davenport at (925) 979-3255 with any questions concerning
your Group Universal Life Insurance policy.

 

Your Disability Coverage

 

Short-term disability (STD) and long-term disability (LTD) insurance
work together to provide you with income if you become disabled by illness or
injury and are unable to work. Officers are automatically enrolled in these
plans.

 

Short-Term Disability

 

In the event you are disabled and unable to perform all the essential
duties of your job, the Company will continue your base annual salary for up to
26 weeks. All disabilities are subject to review. This benefit payment will be
reduced by any benefits payable under Workers’ Compensation and/or any other
state or federal disability benefits you are eligible to receive.

 

Benefits received under this program are considered taxable income.

 

Long-Term Disability

 

If you are disabled longer than 26 weeks, you may be eligible for a
Long-Term Disability benefit based upon your total compensation (September 1,
2002 benefit salary (see page 25 for definition) plus 2002 target management
bonus).

 

Your disability benefits will be subject to preexisting condition
limitations. No benefits will be payable during the first 12 consecutive months
of coverage if you become disabled as the result of a condition for which
treatment was rendered, prescribed, or recommended within three months
immediately preceding the date your benefit option became effective.

 

What is the cost of this benefit?

 

The Company pays the entire cost of this coverage. As such, if you
receive any LTD benefits, they are fully taxable.

 

What happens at termination/retirement?

 

Coverage ceases and cannot be continued or converted.

 

33

 

Comprehensive Executive Non-Qualified
Retirement Plan

 

This Plan provides Officers with an opportunity to defer a portion of
their compensation for retirement or other future needs. The Plan also provides
an opportunity to recover Company contributions limited due to IRS regulations.

 

Eligibility

 

Unless otherwise notified, an Officer of the Company whose base annual
salary plus target management bonus exceeds $125,000 per year is eligible to
participate in the Plan. Generally, deferral elections must be made before the
calendar year in which the compensation is earned and cannot be changed until
the next calendar year. Associates promoted to an Officer position or newly
hired Officers may elect within 30 days to participate in the Plan for the
remaining portion of the calendar year.

 

Deferral Elections

 

There are six basic components to the Plan.

 

1.  Supplemental
401(k) Deferral

 

This component allows you to receive a Company match on eligible
compensation when you have reached the maximum match or are not yet eligible
for a match under the qualified 401(k) plan.

 

This component works in two ways:

 

•                  It replaces deferrals limited due to IRS
regulations on contributions to the 401(k) plan. For 2003, the IRS limits
eligible 401(k) compensation to $200,000 with a maximum contribution of
$12,000. You may defer up to 6% of your compensation earned after reaching
$200,000 or after deferring $12,000 into the 401(k) plan, whichever occurs
first.

 

•                  It allows newly hired Officers to receive a
matching contribution during their first year of service. Newly hired Officers
may defer up to 6% of eligible compensation earned before becoming eligible for
the 401(k) match. Please note: newly hired Officers who elect to defer under this
component need to enroll in the 401(k) Plan with Vanguard when they reach one
year of service in order to continue their contributions and receive the
Company match.

 

2.  Salary Deferral

 

This component allows you to defer up to 60% of your base salary.

 

For example:

 

	
   

  	
   

  	
  Before
  March

  Increase

  	
   

  	
  After March

  Increase

  	
   

  
	
  Base
  salary

  	
   

  	
  $

  	
  140,000

  	
   

  	
  $

  	
  147,000

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Base
  salary deferral election

  	
   

  	
  20

  	
  %

  	
  20

  	
  %

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Annual
  deferred

  	
   

  	
  $

  	
  28,000

  	
   

  	
  $

  	
  29,400

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
  ÷26

  	
   

  	
  ÷26

  	
   

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Amount
  deferred  per pay period

  	
   

  	
  $

  	
  1,076.92

  	
   

  	
  $

  	
  1,130.77

  	
   

  

 

Using the above example, before the March increase, you may elect to
defer between 1%—60% of $140,000. The deferral will take place on a
per-pay-period basis and will reflect the base salary paid during that pay
period. If you elected to defer 20% of the $140,000, you would defer $1,076.92
per pay period. Additionally, if you were to receive a 5% salary increase in
March, bringing your base salary to $147,000, your deferral would increase to
$1,130.77 per pay period ($29,400 ÷ 26 = $1,130.77).

 

3.              Bonus Deferral

 

This component allows you to defer all or a portion (1%—100%) of your
management bonus. This election is for the management bonus that will be earned in the next calendar
year, but not paid until the following year.

 

34

 

4.              Bonus Restricted Stock Award
Deferral

 

Under the Company’s bonus plans, if your earned bonus award is more
than $3,000 over 150% of the target award, then any amounts in excess of 150%
of the target award will be paid in restricted stock, which generally vests
over three years. You may defer all or a portion (1-100%) of the restricted
stock award payable to you for the 2003 performance year. This election is for
the management bonus that will be earned in the 2003 calendar year, but not paid until
the following year.

 

5.              Car Allowance

 

This component allows you to defer your car allowance. You may elect to
defer all of this amount. If you do not defer your car allowance, you will
receive it as taxable income each pay period over the calendar year.

 

You may also elect to be paid for mileage in lieu of the set dollar car
allowance.

 

6.              Supplemental Pension
Deferral

 

This component replaces deferrals limited due to IRS regulations on
contributions to the Pension Accumulation Plan. The Company will automatically
contribute 3%, 4%, or 5% (based on service) of your earnings in excess of
$200,000 per year. There is no election
necessary. This component has a vesting feature identical to the
Pension Accumulation Plan: if you leave prior to completing five years of
credited service, no benefit is payable.

 

Plan
Options

 

Once you decide to make deferral elections under the Comprehensive
Executive Non-Qualified Retirement Plan, you have a number of options, which
are summarized below.

 

Investment
Funds

 

Money deferred under the six components of this Plan is invested in an
account with Vanguard. The same Vanguard funds offered in the WellPoint 401(k)
Retirement Savings Plan are available for your non-qualified deferrals in this
Plan. New participants must make investment elections on the enrollment form.
Current participants can change their investment allocation for new
contributions or for existing balances by calling Vanguard at (800) 523-1188.

 

Distribution of Benefits

 

Officers currently enrolled in this Plan have made payment elections
for their Plan accounts which are on file with the Company. If you are
enrolling for the first time, you must elect the timing of when to receive the
deferral account balance and what form of payment you want to receive. Please
complete and submit the Distribution and Beneficiary Election Form. Note that
the distribution date is the day the distribution processing begins and not the
day you will receive funds.

 

The timing options are:

 

•                  Termination/retirement date

 

•                  Date of death

 

•                  A specific date (must be at least 12 months from
date of election and not later than your 65th birthday)

 

•                  The earliest of your termination/retirement
date, date of death or a specific date

 

•                  Other: this option is used when you elect to
receive the distribution at different intervals (e.g., $25,000 on 7/1/2005,
with the balance at retirement or one year after termination/retirement).

 

The payment options are:

 

•                  Lump sum

 

•                  Annual installments not to exceed 15

 

•                  Other: this option is used if you want a
combination of the above (e.g., $25,000 in a lump sum with the balance in 10
annual installments).

 

35

 

Distribution Processing

 

The Company will begin processing your distribution on the date
specified in your distribution election. Investments must be sold, money
transferred to the trustee, and a check generated by the trustee must be
processed by WellPoint. Please allow a minimum of two weeks after your
distribution date to receive your funds.

 

Changing your Distribution Election

 

You may change an existing distribution election by submitting a
written request at least 12 months BEFORE you are originally scheduled to
receive the distribution. The new election date must be at least 12 months
after the date we receive your new election form. Please contact Steve Selby in
the WellPoint Compensation Department for a new form.

 

Accelerated Distributions

 

•                  Hardship Withdrawal: 
If you have an
immediate and heavy financial need and have no other resources reasonably
available to you, you may request a hardship withdrawal. The 401(k) provisions
regarding hardship withdrawal will be applied. The amount is limited to the
portion of your account attributable to your salary, management bonus, and
supplemental 401(k) deferrals.

 

•                  Forfeiture:  Absent a demonstration of immediate and heavy
financial need, you may elect to receive 85% of your entire vested account in
an early distribution at any time upon 30 days written request. The remaining
15% will be forfeited. If you elect to receive a forfeiture distribution, your
participation in the Plan will be suspended and you may not again participate
in the plan until the Plan Year that is at least 12 months following the Plan
Year in which such distribution occurred.

 

Withholding

 

The Company will deduct amounts required by law to be withheld for
taxes with respect to benefits under this Plan.

 

Beneficiary Election

 

Officers currently enrolled in this Plan have a beneficiary election on
file. New enrollees must make a beneficiary election. Your beneficiary election
may be changed at any time.

 

Suspension of Your Salary, Bonus, and Car
Allowance Deferral Elections

 

You may suspend your election for the salary, bonus, and car allowance
deferral portions of the Plan. You will be eligible to elect deferrals again
for the calendar year following 12 months of suspension.

 

You may limit this suspension to either salary and car allowance
deferrals or bonus deferrals; in either case, future elections will only be
limited for the suspended deferrals.

 

For the bonus deferral, a suspension will affect multiple bonuses: any
bonus deferral that has already been elected and the bonus deferral that would
be elected within 12 months of suspension.

 

Suspension of Your Supplemental 401(k)
Deferral

 

You may separately suspend your election for the supplemental 401(k)
deferral. You will be eligible to elect deferrals again for the calendar year
following 12 months of suspension.

 

36

 

Your Balanced Life Benefits

 

WellPoint knows that you want a career, but you also want balance with
your personal life. For this reason, the Company provides a wide range of
benefit programs to assist you in balancing your life and career.

 

The following information briefly outlines some of these current
benefits. Please refer to your Associate Handbook for more details. The legal
plan documents are controlling in any conflict of interpretation, and the
Company reserves the right to modify or terminate the programs at any time
without notice.

 

Employee Assistance and Work/Life Program

 

WellPoint offers an Employee Assistance and Work/Life Program to help
you find solutions to the problems and difficulties of daily life. WellPoint
offers its Employee Assistance Program (EAP), free of cost, through WellPoint
Behavioral Health (WBH). This program is available to all associates from date
of hire.

 

The EAP provides confidential, professional assistance when personal
problems affect your life and work. EAP counseling and referral services can
assist you with emotional difficulties, relationship issues, family concerns,
alcohol and drug abuse, and financial and legal concerns. Associates and
eligible family members (including domestic partners and their children) may
receive up to six sessions per incident.

 

In addition to offering confidential counseling, the program is
designed to help you make the right decisions about your dependent care needs.
Work/Life benefits include resources and referrals for child care needs and
elder care needs offered through Harris Rothenberg International (HRI).
Counselors can be reached through your EAP toll-free number.

 

EAP professionals are available 24 hours a day, 7 days a week. For
assistance, call the EAP at (888) 777-6665.

 

MedCall

 

MedCall is a 24-hour, 7-day a week nurse line. There is no cost for
using this service. All associates and their families have access to nurse
counselors who can provide a variety of information including:

 

•                                Assistance in determining if you need to see
a doctor,

•                                What level of care would be the most
appropriate (e.g., hospital vs. urgent care facility),

•                                Information on various health conditions and
diagnoses,

•                                Information on medical procedures,

•                                Information on various support groups,
medications, and possible side effects, and

•                                General health information.

 

MedCall also provides guidance regarding questions you should ask your
provider and access to an audio library of over 200 health-related topics.
MedCall can be reached at (888) 629-4000. Your custom MedCall ID # is 1005.

 

These services are available to associates in Georgia and their
dependents by calling Blue Choice On Call at (888) 724-BLUE (2583).

 

Tuition Assistance

 

WellPoint encourages you to increase your knowledge and develop your
career. All active, full-time regular associates who complete six months of
service are eligible to request tuition assistance. Classes must begin after
the 6-month waiting period. To

 

37

 

participate in the program, applications for tuition assistance must be
approved by your supervisor prior to enrolling in any course.

 

The benefit is 75% of tuition and related expenses up to a $3,000
maximum reimbursement per year. This benefit may be reduced by any grants or
scholarships you receive. (Per current IRS rules, reimbursement for
undergraduate courses is not included in income, but graduate level course
reimbursement is taxable income.)

 

Academic courses and degree programs either must be related to a
currently held job or to a position at the Company for which you are preparing to
qualify. Courses must be taken at an accredited institution based in the U.S.
Upon successful completion of the course (a “C” grade or better for
undergraduate courses and a “B” grade or better for graduate courses—or “pass”
where the course is “pass/fail”), you will be reimbursed for registration,
tuition, laboratory fees, required books, and required software. Requests for
reimbursement must be completed within 90 days of completing the course.
Tuition assistance applications are available at your local Human Resources
office.

 

For a more detailed description of the policy on the
Tuition Assistance Program, please refer to the Intranet at WorkSite>
Corporate Links>Human Resources> Library>Training and Education. If
you have any questions, contact your supervisor or the Associate Service Center
at (877) 342-5272.

 

Work On Wellness (WOW)

 

Practicing a healthy lifestyle cuts down on stress and reduces the
likelihood of illness and injury. To support this philosophy, the Company
offers Work On Wellness (WOW) to all active, regular full-time associates
following six months of active employment. WOW provides reimbursement for
individual membership dues in health clubs, fitness/yoga programs, smoking
cessation programs, or weight management programs, up to a maximum of $35 per
month. Reimbursement is taxable income and is treated as “other” income and
reported on your W-2 form. Reimbursement is made quarterly through your
paycheck. If your spouse/domestic partner is also an associate, each of you is
eligible for WOW reimbursement up to $35 per month.

 

You must submit a WOW reimbursement form and receipts quarterly for
eligible expenses to the Associate Service Center within 30 days of the close
of the calendar quarter for which you are requesting reimbursement. You may
print a copy of the WOW form from WorkSite.

 

Time Off

 

Time off includes Company holidays and paid time off (“PTO”), which can
be used for vacation, illnesses, leaves of absence, and other reasons.

 

Holidays

 

WellPoint provides eligible Officers 10 paid Company holidays each
year. The scheduled days vary somewhat each year because holidays fall on
different days of the week from one year to the next. The Company holiday
schedule for 2003 is in the Associate Handbook.

 

Paid Time Off

 

The Officers’ paid time off accrual schedule will be communicated in
the 2003 Associate Handbook.

 

Leaves Of Absence

 

The Company provides different leave plans to accommodate associates
when certain situations arise that would temporarily make working unduly
burdensome. The plans include Medical/Pregnancy Disability Leave, Family
Care/Bonding Leave, Military Leave, and Personal Leave. The Company administers
leaves of absence in accordance with the Family Medical Leave Act, the
Americans with Disabilities Act, and all other federal and state laws governing
leaves of absence. The plans are described in detail in the Summary Plan
Descriptions.

 

38

 

Your Financial Future and Retirement Benefits

 

Pension Accumulation Plan

 

On the January 1 or July 1 following one year of service and reaching
age 21, you automatically participate in the Pension Accumulation Plan.
Benefits under the Plan are fully paid by the Company and are based on earnings
and length of service. For new Officers, the Company contribution is generally
3% of eligible earnings for less than 10 years of service; 4% of earnings
during years 10 through 19; and 5% of earnings for any years of service after
20. Officers who complete five years of credited service are fully vested.
There is no partial vesting for less than five years of service. Statements
will be mailed to your home address on an annual basis.

 

WellPoint 401(k) Retirement Savings Plan

 

WellPoint’s 401(k) Retirement Savings Plan is a retirement plan
designed to help you save for long-term financial goals, especially retirement.
You contribute to the Plan through automatic payroll deductions and benefit
from special tax advantages.

 

Contributions

 

You may start contributions on the first of the month following one
month of completed service and reaching age 18. An enrollment package will be
mailed to your home from Vanguard, our plan trustee. Please refer to the
enrollment materials, Summary Plan Description/Prospectus and plan document for
a description of this Plan and before making any decision to participate in the
Plan.

 

Contributions are made on a pretax basis and are based on your eligible
compensation. You can contribute between 1% and 20% of your eligible
compensation, subject to the following limitations:

 

•                  Officers who earn more than $90,000 are
considered by the IRS to be highly compensated. This limit will be adjusted
periodically by the IRS. This plan currently limits highly compensated Officers
to a maximum contribution of 8% of eligible compensation and may be adjusted as
necessary.

 

•                  The IRS limits pretax contributions to an
annual limit of $12,000 in 2003. This limit will be adjusted periodically by
the IRS.

 

•                  You may continue your contributions, subject
to the $12,000 limit, until your eligible earnings reach $200,000, or as
adjusted by the IRS.

 

39

 

Company Match

 

Generally, after one year of employment, the Company matches a portion
of your eligible contributions. Beginning with the pay period in which you
reach one year of employment, the Company will generally match 75 cents for
each dollar up to 6% of your eligible earnings that you contribute to the plan.
One-third of the Company match will be invested in the WellPoint Common Stock
Fund. You may redistribute the value of the units and reinvest the money in
another fund within your 401(k) plan at any time. You determine the investment
direction for the rest of the Company match. In order to maximize the Company
match, you must contribute 6% to the Plan.

 

	
  Example:

  	
   

  	
   

  	
   

  
	
   

  	
   

  	
   

  	
   

  
	
  Eligible
  Compensation:

  	
   

  	
  $400

  	
   

  
	
  Contribution
  of 6%:

  	
   

  	
  $24

  	
   

  
	
  Company
  Match of 41⁄2%

  	
   

  	
  $18

  	
   

  
	
  (75 cents for each dollar up to 6%)

  	
   

  	
  ($6
  invested in WellPoint

  Common Stock; $12 you

  choose how to invest)

  	
   

  

 

Vesting

 

You are 100% vested in pretax contributions as well as the Company
matching contributions. So, when you retire or terminate employment, you may
receive all the assets in your Plan account. The portion of the Company match
directed to the WellPoint Common Stock Fund must be maintained in that fund for
the period specified in the Plan.

 

Investment Choices

 

When you enroll in the Plan, you choose how to invest your
contributions. There are many investment choices available. You may change your
fund selection, transfer contributions between funds or change you contribution
percentage at any time by calling Vanguard’s VOICE Network at (800) 523-1188,
24 hours a day or by visiting Vanguard’s web site at www.Vanguard.com.
If you prefer, a Vanguard associate can assist you with investment changes
during normal business hours (M-F from 8:30 a.m. to 9:00 p.m. Eastern Time). To
access your account, you must have your Social Security number and your
assigned Personal Identification Number (PIN).

 

Access to Your Savings

 

The Plan is designed to encourage long-term savings, but you may access
money from the Plan under certain circumstances. The Plan offers loans and
hardship withdrawals. Please see your enrollment materials and the Summary Plan
Description/Prospectus for details and before making any decision to
participate in the Plan.

 

Employee Stock Purchase Plan

 

You may enroll in the Employee Stock Purchase Plan if you are employed
on the day preceding the first day of the offering period. Enrollment is twice
a year—in December, reflecting the January to June offering period, and in
June, reflecting the July to December offering period. Enrollment materials
will be mailed to your home with instructions. At the end of each offering
period, your contributions are used to purchase WellPoint Common Stock at a
rate discounted from the market price at the time of purchase.

 

The stock purchase price is set at the lower of the Company stock price
on the first day of the offering period or on the last day of the offering
period. This is subject to plan terms and limits. Refer to the Summary Plan
Description/Prospectus for further details. Associates pay only 85% of this
price.

 

You may choose to keep or sell your shares and are responsible for
brokerage fees, capital gains taxes, and any other costs associated with the
sale.

 

Please refer to the Summary Plan Description/Prospectus before making
any decision to participate in the Employee Stock Purchase Plan.

 

40

 

Mid-Year Changes

 

Generally, you will not be able to change your FlexPoint elections until the next Open
Enrollment period. However, IRS rules and the plans allow you to change your
elections during the year if you have a qualified mid-year change.

 

Qualified Mid-Year Changes

 

Examples of qualified mid-year changes for which you can change some of
your benefits during the year include:

 

•                  Marriage, change in domestic partner status,
divorce, legal separation, or annulment

 

•                  Birth or adoption of a child, or a change in
a child custody arrangement

 

•                  Death of your spouse/domestic partner or
dependent

 

•                  A change in your spouse’s/domestic
partner’s/dependent’s employment status

 

•                  A significant change in your
spouse’s/domestic partner’s/dependent’s employer’s health care coverage,
including Open Enrollment

 

•                  A change in a dependent’s eligibility status
because of marriage, age, or loss of dependent status for federal tax purposes

 

•                  A change in the cost of your dependent
daycare

 

•                  Unpaid leaves of absence

 

The coverage change must be consistent with the qualifying event.

 

If a qualified mid-year change occurs, it is your responsibility to
contact the Associate Service Center within 31 days of the qualifying event.
After you report the event to the Associate Service Center, you will receive an
Enrollment Worksheet for your use in making changes to your benefits. You will
need to complete the Enrollment Worksheet and return it with the appropriate
documentation by the deadline listed on the form. Failure to act promptly could
result in not having coverage for which you or your dependents would otherwise
be eligible.

 

Continuing coverage for a dependent who is no longer eligible (i.e.,
divorce, termination of domestic partnership, a dependent child reaching the
maximum age, etc.), is a violation of Company policy and subject to
disciplinary action up to and including termination of employment. WellPoint
pays for a portion of coverage for these individuals. You may be liable for
premiums and all expenditures including, but not limited to, claims costs and
any fees necessary to be reimbursed for any paid claims, as well as legal fees.

 

If you move to an area where an HMO, Dental Net, or a PPO is not
available, you must change your option to one that is available in your new
location. However, no other benefit changes will be allowed.

 

The chart on the following pages shows the changes you can make during
the year. For allowable domestic partner changes, refer to the Domestic Partner
Guide.

 

41

 

Qualified
Mid-Year Changes

 

	
  Event*

  	
   

  	
  Election Changes You Can Make

  Within 31 Days of the Event

  	
   

  	
  Coverage/Change

  Effective Date

  	
   

  	
  Documentation

  Required

  
	
  You get married 

  	
   

  	
  •                  Enroll yourself, spouse, and your spouse’s
  dependent Date of the event Copy of marriage certificate children in Medical,
  Dental, and/or Vision (may not change existing plans) 

  •                  Cancel Medical, Dental, and/or Vision for
  yourself and dependent children if you are electing coverage under your new
  spouse’s plan 

  •                  Add Spouse Life 

  •                  Enroll in/increase Health Care Spending
  Account 

  •                  Enroll in/cancel/change amount of
  contribution to Dependent Day Care Spending Account

  	
   

  	
  Date of the event

  	
   

  	
  Copy of marriage certificate

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  You get divorced, legally separated, or have your
  marriage annulled 

  	
   

  	
  •                  Enroll yourself and dependent children in
  Medical, Dental, and/or Vision if you and your dependent children lose
  coverage under your former spouse’s plan(s) 

  •                  Required to cancel spouse in Medical,
  Dental, and Vision (COBRA coverage will be available for your spouse)

  •                  Required to cancel Spouse Life and Child
  Life for stepchildren 

  •                  Enroll in/change contribution to Health Care
  Spending Account 

  •                  Enroll in/cancel/change amount of
  contribution to Dependent Day Care Spending Account

  	
   

  	
  Date of the event

  	
   

  	
  Copy of court documents

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  You gain a dependent child through birth, adoption or
  placement for adoption, or gain legal guardianship** 

  	
   

  	
  •                  Enroll yourself, spouse, and dependent
  children in Medical, Dental, and/or Vision 

  •                  Add new dependent child to existing Child
  Life coverage or enroll an only child 

  •                  Enroll in/increase Health Care Spending
  Account 

  •                  Enroll in/increase Dependent Day Care
  Spending Account

  	
   

  	
  Date of the event

  	
   

  	
  Copy of birth certificate from hospital, copy of adoption papers, or
  copy of court documents for legal guardianship 

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your and/or your spouse’s dependent child becomes
  ineligible (i.e., marriage, over maximum age, becomes a WellPoint associate,
  etc.) or you lose legal custody of a child 

  	
   

  	
  •                  Required to cancel dependent child in
  Medical, Dental, Vision, and Child Life (may be eligible for COBRA) 

  •                  Cancel (if ineligible dependent is only
  person covered) or decrease Dependent Day Care Spending Account

  	
   

  	
  End of the month

  	
   

  	
  Copy of court documents for legal custody  None required for marriage, over maximum age, etc.

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your spouse dies

  	
   

  	
  •                  Required to cancel spouse in Medical,
  Dental, Vision, and Spouse Life 

  •                  Enroll yourself and dependent children in
  Medical, Dental, Vision, and Health Care Spending Account if you and your
  dependent children lose coverage under your deceased spouse’s plan(s) 

  •                  Change amount of Health Care Spending
  Account 

  •                  Enroll in/change amount of Dependent Day
  Care Spending Account

  	
   

  	
  Date of death

  	
   

  	
  Copy of death certificate

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your dependent child dies

  	
   

  	
  •                  Required to cancel dependent child in
  Medical, Dental, Vision, and Child Life 

  •                  Decrease Health Care Spending Account 

  •                  Decrease Dependent Day Care Spending Account

  	
   

  	
  Date of death

  	
   

  	
  Copy of death certificate

  

 

*         For allowable domestic partner changes, refer to the Domestic Partner
Guide.

 

**    For PPO, Group, Blue Cross HMO, Blue Choice Healthcare, UNICARE HMO,
UNICARE Health Plan of Texas, BlueCHOICE HMO and HealthLink HMO plans, election
changes for birth or adoption can be made within 60 days of the event. For non-WellPoint
plans, the HMO will make the decision to add the newborn/adopted child, after
the 31-day period has passed, on a case by case basis.

 

42

 

	
  Event*

  	
   

  	
  Election Changes You Can Make

  Within 31 Days of the Event

  	
   

  	
  Coverage/Change

  Effective Date

  	
   

  	
  Documentation

  Required

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your spouse begins employment or increases his/her
  work hours and gains Medical, Dental, and/or Vision coverage through his/her
  employer

  	
   

  	
  •                  Cancel yourself, spouse, and/or dependent
  children in Medical, Dental, and/or Vision 

  •                  Change contribution to Health Care Spending
  Account 

  •                  Enroll in/increase Dependent Day Care
  Spending Account

  	
   

  	
  Date of the event

  	
   

  	
  Documentation from spouse’s employer (i.e., benefits enrollment form,
  employment offer letter, etc.)

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your spouse ends employment or loses eligibility for
  benefits and you/your spouse/your dependent children lose Medical, Dental,
  and/or Vision coverage through his/her employer

  	
   

  	
  •                  Enroll yourself, spouse, and/or dependent
  children in Medical, Dental, and/or Vision 

  •                  Enroll in/change contribution to Health Care
  Spending Account 

  •                  Cancel/decrease Dependent Day Care Spending
  Account

  	
   

  	
  Date of the event

  	
   

  	
  Documentation from spouse’s employer (i.e., COBRA notice, HIPAA
  notice, etc.)

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your and/or your spouse’s dependent ends employment
  or loses eligibility for benefits through his/her employer

  	
   

  	
  •                  Enroll dependent in Medical, Dental, and/or
  Vision 

  •                  Change contribution to Health Care Spending
  Account

  	
   

  	
  Date of the event

  	
   

  	
  Documentation from dependent’s employer (i.e., COBRA notice, HIPAA
  notice, etc.) and proof of full-time student status

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your spouse or dependent child begins full-time
  employment at WellPoint

  	
   

  	
  •                  Required to cancel Spouse/Child Life

  	
   

  	
  Date spouse or dependent child qualifies for benefits

  	
   

  	
  None—Provide name and Social Security Number of spouse/dependent child

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your and/or your spouse’s dependent child begins
  employment or increases work hours and gains coverage through his/her
  employer

  	
   

  	
  •                  Cancel Medical, Dental, Vision, and Child
  Life for dependent child 

  •                  Change contribution to Health Care Spending
  Account

  	
   

  	
  Date of the event

  	
   

  	
  Documentation from dependent’s employer (i.e., benefits enrollment
  form, employment offer letter, etc.)

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  You move outside HMO or PPO Service Area

  	
   

  	
  •                  Required to elect new Medical plan in new
  location

  	
   

  	
  Date of the event

  	
   

  	
  Address change

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  You move outside Dental Net Service Area

  	
   

  	
  •                  Enroll in new Dental plan

  	
   

  	
  Date of the event

  	
   

  	
  Address change

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your job status changes from part-time to full-time

  	
   

  	
  •                  Enroll in Medical, Dental, Vision, Employee
  Life, AD&D, Spouse Life, Child Life, STD, and LTD 

  •                  Enroll in/increase Health Care Spending
  Account 

  •                  Enroll in/increase Dependent Day Care
  Spending Account

  	
   

  	
  First of the month following job status change

  	
   

  	
  None-Human Resources action

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your job status changes from part-time (under 20
  hours/week) to part-time at least 20 hours/week

  	
   

  	
  •                  Enroll yourself, spouse, and dependent
  children in Medical 

  •                  Enroll in Health Care Spending Account 

  •                  Enroll in Dependent Day Care Spending
  Account

  	
   

  	
  First of the month following job status change

  	
   

  	
  None-Human Resources action

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your job status changes from full-time to part-time
  (at least 20 hours/week)

  	
   

  	
  •                  Change Medical plan 

  •                  Required to cancel Dental, Vision, STD, LTD,
  Employee Life, AD&D, Spouse Life, and Child Life (COBRA may be available)
  

  •                  Enroll in/cancel/change contribution to
  Health Care Spending Account  

  •                  Cancel/decrease Dependent Day Care Spending
  Account

  	
   

  	
  First of the month following job status change

  	
   

  	
  None—Human Resources action

  
	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  	
   

  
	
  Your job status changes from full-time to part-time
  (less than 20 hours/week)

  	
   

  	
  •                  Required to cancel Medical, Dental, Vision,
  STD, LTD, 

  •                  Employee Life, Spouse Life, Child Life, Health
  Care and 

  •                  Dependent Day Care Spending Account (COBRA
  may be available)

  	
   

  	
  First of the month following job status change

  	
   

  	
  None—Human Resources action

  

 

Important Note: The allowable changes are
permitted only if they are consistent with and on account of your change
in status as determined under IRS regulations.

 

*  For allowable domestic partner changes,
refer to the Domestic Partner Guide.

 

43

 

Continuing Health Care Coverage
("COBRA")

 

This is a summary of your rights and obligations under the COBRA
continuation coverage provisions. Both you
and your spouse, if any, should take the time to read this notice carefully. Domestic
partners and children of domestic partners are not eligible for COBRA continuation.

 

COBRA requires that most Officers of WellPoint and its related
companies and their families receive the opportunity for a temporary extension
of health care coverage, called “continuation coverage,” at group rates in
certain instances where coverage under the WellPoint Companies’ Group Health
Plans (“Health Plans”) would end. For this purpose, the term “Health Plans”
includes the WellPoint Companies’ medical, dental, vision, employee assistance,
and health care flexible spending account plans, and the term “qualified
beneficiary” is used below to refer to individuals who are eligible to receive
COBRA continuation coverage.

 

Qualifying Events For Officers

 

If you are an Officer of the WellPoint Companies covered by a Health
Plan, you have the right to choose COBRA continuation coverage if you lose your
Health Plan coverage because of the following:

 

•                  A reduction in your hours of employment, or

 

•                  The termination of your employment (for
reasons other than gross misconduct on your part).

 

Qualifying Events for Spouse and Dependent
Children

 

If you are the spouse or a dependent child of an Officer covered by a
Health Plan, you have the right to choose continuation coverage for yourself if
you lose coverage for any of
the following reasons:

 

•                  The death of your spouse

 

•                  A termination of your spouse’s employment
(for reasons other than gross misconduct) or reduction in your spouse’s hours
of employment 

 

•                  Divorce or legal separation from your spouse 

 

•                  Your spouse becomes entitled to Medicare 

 

•                  You reach the maximum age allowed to be
considered a dependent child 

 

•                  You are no longer considered a dependent
child.

 

There is no COBRA continuation coverage for domestic partners or their
children.

 

Deadline for Election

 

When the Plan Administrator is notified that one of these qualifying
events has happened, the Administrator will, in turn, notify you that you have
the right to choose continuation coverage. Under COBRA, you have the later of
60 days from the date you receive the notice or 60 days from the date that you would lose
coverage because of one of the qualifying events described above to inform the
Plan Administrator that you want continuation coverage. If you do not choose
continuation coverage, your group Health Plan coverage will end.

 

Type of Coverage

 

If you choose continuation coverage, the WellPoint Companies are
required to give you coverage which, as of the time coverage is being provided,
is identical to the coverage provided under the Health Plan to similarly
situated Officers or family members.

 

44

 

Length of Coverage

 

COBRA requires that you be afforded the opportunity to maintain
continuation coverage for 36 months unless you lost Health Plan coverage
because of a termination of employment or reduction in hours. In that case, the
required continuation coverage period is 18 months.

 

The 18-month period may be extended to 29 months if a qualified
beneficiary is determined by the Social Security Administration to be disabled
(for Social Security disability purposes) at any time during the first 60 days
of COBRA coverage. This 11-month extension is available to all individuals who
are qualified beneficiaries due to a termination or reduction in hours of
employment. To benefit from this extension, a qualified beneficiary must notify
the Plan Administrator within 60 days from the date on which the disability was
determined. This notification must also occur before the end of the original
18-month period. The affected individual must also notify the Plan
Administrator within 30 days of the date on which the individual is determined
no longer to be disabled.

 

The 18- or 29-month period may be extended if other qualifying events
(for example, divorce, death, or entitlement to Medicare) occur during the period.
Coverage will not be extended beyond 36 months from the date of the qualifying
event that originally made you eligible to elect COBRA continuation coverage.

 

A child who is born to or placed for adoption with the covered Officer
during a period of COBRA coverage will be eligible to become a qualified
beneficiary if the Plan Administrator is notified within 31 days of the birth
or placement of the child.

 

Early Termination of Coverage

 

COBRA provides that your continuation coverage may be shortened for any of the following five reasons:

 

•                  The WellPoint Companies no longer provide
group health coverage to any of their associates;

 

•                  The premium for continuation coverage is not
paid on time;

 

•                  The qualified beneficiary becomes covered
under another group health plan that does not contain any exclusion or
limitation for any pre-existing condition that affects the qualified
beneficiary;

 

•                  The qualified beneficiary becomes entitled to
Medicare;

 

•                  The qualified beneficiary has already
received 18 months of coverage due to disability, and there has been a final
determination that the qualified beneficiary is no longer disabled.

 

The Plan Administrator reserves the right to terminate your COBRA
coverage retroactively if you are determined to be ineligible for COBRA.

 

Cost of Coverage

 

You do not have to show that you are insurable to choose continuation
coverage. However, the law provides for payment by the qualified beneficiary of
100% of the premium for continuation coverage plus an administrative fee. The
cost of continuation will be 102% of the premiums. However, if you are eligible
to extend continuation of coverage for an additional 11 months due to
disability, the cost of continuation for any additional months will be 150% of
the premiums. There is a grace period of 30 days for the regularly scheduled
premium.

 

Cancellation for Non-Payment

 

•                  Premiums are due on the last day of the
calendar month preceding coverage.

 

•                  Coverage will be cancelled if payment is not
received within 30 days of the due date.

 

•                  It is the participant’s responsibility to
make sure premiums are received by the due date, allowing sufficient mail time.

 

•                  Once coverage is cancelled for nonpayment, it
will not be reinstated.

 

Additional Information

 

If you have any questions about COBRA, please contact the Associate
Service Center.

 

45

 

Important Information

 

Actively At Work

 

If you are not actively at work on a full-time basis on the day your
coverage or an increase in your benefits would otherwise begin, then your
coverage or an increase in benefits will not begin until the date you return to
active work on a full-time basis.

 

If you elect a medical plan offered by WellPoint, coverage will become
effective under the Plan even if you are hospitalized or on medical leave on
the effective date.

 

The Health Insurance Portability and
Accountability Act of 1996 (HIPAA)

 

Pre-existing conditions exclusions have been eliminated from the PPO
and Group Medical Plans (for pre-existing conditions on LTD/STD, please see
page 33). Special enrollment provisions for associates declining medical
coverage have been adopted.

 

Special Enrollment Rights

 

If you are declining enrollment for yourself or your dependents because
of other health insurance coverage, you may be able to enroll yourself or your
dependents in the future in a medical plan offered by WellPoint, provided that
you request enrollment within 31days after your other coverage ends.

 

In addition, if you have a new dependent or other person eligible under
our plans as a result of marriage, domestic partnership, birth, adoption, or
placement for adoption, you may be able to enroll yourself and other eligible
persons, provided that you request enrollment within 31 days after the
marriage, birth, adoption, or placement for adoption.

 

Newborn’s and Mother’s Protection Act

 

Group health plans and health insurance issuers generally may not,
under federal law, restrict benefits for any hospital length of stay in
connection with childbirth for the mother or newborn child to less than 48
hours following a vaginal delivery, or less than 96 hours following a cesarean
section. However, federal law generally does not prohibit the mother’s or
newborn’s attending provider, after consulting with the mother, from
discharging the mother or her newborn earlier than 48 hours (or 96 hours as
applicable). In any case, plans and issuers may not, under federal law, require
that a provider obtain authorization from the plan or the insurance issuer for
prescribing a length of stay not in excess or 48 hours (or 96 hours).

 

46

 

Women’s Health and Cancer Rights Act of 1998

 

The Women’s Health and Cancer Rights Act of 1998 was enacted on October
21, 1998 and requires that all health plans cover post-mastectomy breast
surgery if they provide medical and surgical coverage for mastectomies. If you
and/or your eligible dependents receive these benefits under a
WellPoint-sponsored medical plan, the plan must cover:

 

•                  Reconstruction of the breast on which the
mastectomy was performed;

 

•                  Surgery and reconstruction of the other
breast to produce a symmetrical appearance;

 

•                  Prostheses; and

 

•                  Treatment for physical complications of all
stages of mastectomy, including lymphedemas.

 

Benefits required under the Women’s Health and Cancer Rights Act will
be provided in consultation between the patient and attending physician. These
benefits are subject to the same health plan deductibles, copayments, and
coinsurance that apply to any other benefit under the specific plan and cannot
be denied or reduced on the grounds that they are cosmetic in nature or that
they otherwise do not meet the plan’s definition of “medically necessary.”

 

If you are enrolled in an HMO offered by WellPoint, please be aware
that several states have enacted similar laws requiring coverage for treatment
related to mastectomies. If the similar law of the state in which your HMO is
located is more generous than the federal law, your benefits will be paid in
accordance with your state’s law.

 

47

 

Important
Telephone Numbers

 

	
  Associate Service Center

  	
  (877) 342-5272

  	 

	
  Medical

  	
   

  	 

	
  PPO

  	
  (800) 234-0111

  	 

	
  Group

  	
  (800) 234-0111

  	 

	
  PPO (Georgia)

  	
  (800) 441-2273

  	 

	
  PPO (Missouri)

  	
  (800) 556-6769

  	 

	
  PPO

  	
  (Missouri-HealthLink)

  	
   

  
	
   

  	
  Customer/provider inquiry

  	
  (800) 624-2356

  
	
   

  	
  Eligibility, claims and benefits

  	
  (800) 556-6769

  
	
  HMOs

  	
   

  	
   

  
	
  CA:

  	
  Blue Cross HMO

  	
  (800) 234-0111

  
	
  GA:

  	
  Blue Choice Healthcare

  	
  (800) 441-2273

  
	
  IL:

  	
  UNICARE HMO (Illinois)

  	
  (800) 234-0111

  
	
  MA:

  	
  Network Blue

  	
  (800) 588-5509

  
	
  MI:

  	
  Blue Care Network of S.E. Michigan

  	
  (800) 662-6667

  
	
  TX:

  	
  HMO Blue Cross (Dallas/Ft. Worth)

  	
  (888) 558-2393

  
	
   

  	
  UNICARE Health Plan of Texas

  	
  (888) 955-4200

  
	
  MO:

  	
  BlueCHOICE HMO

  	
  (866) 622-8322

  
	
   

  	
  HealthLink HMO

  	
  (800) 624-2356

  
	
   

  	
  Precertification only

  	
  (877) 284-0102

  
	
  Dental

  	
   

  	
   

  
	
  Dental Net (California
  only)

  	
  (800) 627-0004

  	 

	
  WellPoint Standard Dental

  	
  (800) 627-0004

  	 

	
  WellPoint Enhanced Dental

  	
  (800) 627-0004

  	 

	
  Dental ID cards (Georgia)

  	
  (800) 441-2273

  	 

	
  Dental ID cards (Missouri)

  	
  (800) 556-6769

  	 

	
  Vision

  	
   

  	 

	
  VSP

  	
  (800) 877-7195

  	 

	
  Mail Order Prescriptions

  	
  (866) 274-6825

  	 

	
  UniAccount (Flexible Spending Accounts)

  	
  (888) 209-7976

  	 

	
  Blue Choice On Call (Georgia)

  	
  (888) 724-BLUE (2583)

  	 

	
  Group Universal Life Insurance

  	
  (925) 979-3255

  	 

	
  Comprehensive Non-Qualified Retirement Plan

  	
  (805) 557-5801

  	 

	
  MedCall (ID # 1005)

  	
  (888) 629-4000

  	 

	
  Employee Assistance and Work/Life Program

  	
  (888) 777-6665

  	 

	
  Vanguard’s Voice Network

  	
  (800) 523-1188

  	 

	
  Employee Stock Purchase Plan

  	
   

  	 

	
  E*Trade (available after
  11/1/02)

  	
  (800) 838-0908

  	 

 

48

 

Important Addresses for Claims

 

Medical—PPO

 

WellPoint

P.O. Box 4109

Woodland Hills, California 91365

Attn:  Associate Claims Unit

 

Dental

 

WellPoint

P.O. Box 9066

Oxnard, California 93031-9066

Attn:  Associate Claims Unit

 

Vision

 

Vision Service Plan

P.O. Box 997105

Sacramento, California 95899-7105

 

Associates in Georgia

 

Medical

Blue Cross and Blue Shield of Georgia

P.O. Box 9907

Columbus, GA 31908-6007

 

Associates in Missouri

 

Medical—PPO

Blue Cross and Blue Shield of Missouri

P.O. Box 14882

St. Louis, MO 63178-4882

 

Medical—HMO

BlueCHOICE

P.O. Box 66834

St. Louis, MO 63166-6834

 

Medical —HealthLink PPO

HealthLink

P.O. Box 419104

St. Louis, MO 63141-9104

 

Medical —HealthLink HMO

HealthLink

P.O. Box 411580

St. Louis, MO63141-1580

 

Pharmacy Drugs

 

WellPoint Pharmacy

P.O. Box 4165

Woodland Hills, California 91365-4165

 

Mail Order Prescriptions

Prescription Drug Program-Mail Service

P.O. Box 961025

Fort Worth, TX 76161-9863

 

Spending Accounts

 

UniAccount

P.O. Box 4381

Woodland Hills, California 91365-4381

 

49

 

September 2002

 

50

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