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1 Page 1 of 5 Member ID: XDM 654A63564 Name: DO, THANHXUAN F Birth Date: 03/10/1955 Member Code: 20 Relationship: Subscriber Gender: Female Date/Time of Inquiry: 04:58:12 PM PST Plan Information Product Name: BLUE CROSS HMO Effective Date: 05/01/2009 Plan Code: D17 Term Date: Group ID: H001 Status: Active Contract Code: Z4DH Plan State: CA PMG/PCP Information 1-2 Provider Name Effective Date Term Date Provider Address Provider Phone NOBLE AMA IPA MEDICAL GROUP DAO,MICHAEL (NOBLE AMA IPA MEDICAL GROUP) 05/01/2007 Active STUDEBAKER RD CERRITOS, CA /01/2007 Active 9191 WESTMINSTER AVE GARDEN GROVE, CA Categories - Select Categories below and Click to print only selected benefits General Eligibility Maximum Copayments Inpatient Hospitalmedical Inpatient Dental Ambulatory Surgical Centers Skilled Nursing Facilities Medical While Hospitalized Emergency Room And Emergency Diagnosis Benef Outpatient Medical Preventive Care Diabetes Maintenance Well Women Physician Home/office PHO Consultations Electronic Visit Diagnostic X-ray & Lab Hemodialysis

2 Page 2 of 5 Chemotherapy Radiation Therapy Surgery Post Surgical Vision Physical Therapy Chiropractic Acupuncture Rehabilitation Therapies Durable Medical Equipment Pediatric Asthma Equipment Obstetrical Sterilization/infertility Home Health Care Hospice Care Bereavement Counseling Mental Health Parity Inpatient Hospitalnervous/menta Outpatient Nervous/Mental Professional Nervous/Mental Inpatient Substance Abuse Drug Rider Coverage General Provisions Provider Network Benefit Details Action General Eligibility Dependent Eligibilit To All 19 Years Dependent Maximum Age Limit All 24 Years Maximum Copayments Single Party Copayment Maximum HMO $1,500 Family Copayment Maximum HMO $3,000 HMO Provider Network Benefit Details Action Inpatient Hospital-medical Inpatient Per Admission Copayment HMO $0 Inpatient Dental Inpatient Dental Maximum Days HMO 3 Days Ambulatory Surgical Centers Ambulatory Surgical Center (ASC) Copayment HMO $0 Skilled Nursing Facilities Skilled Nursing Copayment HMO $0 Skilled Nursing Facility Maximum Per Calendar Year HMO 100 Days Skilled Nursing Facility N&m Diag Maximum HMO 30 Days Calendar Year Medical While Hospitalized Medical While Hospitalized Copayment HMO $0 Emergency Room And Emergency Diagnosis Benef Emergency Room In Area Copayment HMO $100 Emergency Room In Area Physician Pct HMO 0% Emergency Room Out Of Area Copayment HMO $100 Out Of Area Emergency Room Physician Copayment HMO $0 Outpatient Medical Outpatient Copayment HMO $0

3 Page 3 of 5 Preventive Care Routine Exam Copayment HMO $20 Well Baby Exam Copayment HMO $20 Immunizations Copayment HMO $0 Eye Exam Copayment HMO $20 Hearing Copayment HMO $20 Blood Lead Screen Copayment HMO $0 Health Ed Program Copayment HMO $0 Diabetes Maintenance Diabetes Education Copayment HMO $20 Well Women Well Women Exam Copayment HMO $20 Physician Home/office Home/office Visit Copayment HMO $20 Specialist Copayment HMO $20 Allergy Serum Copayment HMO $0 PHO Consultations Consultation Copayment HMO $20 Electronic Visit Electronic Visit Copayment HMO $10 Diagnostic X-ray & Lab Diagnostic X-ray & Lab Copayment HMO $0 Allergy Testing Copayment HMO $0 Hemodialysis Hemodialysis Copayment HMO $0 Chemotherapy Chemotherapy Copayment HMO $0 Radiation Therapy Radiation Therapy Copayment HMO $0 Surgery Surgery Copayment HMO $0 Assist Surgeon Copayment HMO $0 Anesthesia Copayment HMO $0 Post Surgical Vision Glasses/contacts Following Surgery HMO 1 Occurence Physical Therapy Physical Therapy Copayment HMO $0 Physical Therapy Maximum Per Illness HMO 60 Days Physical Therapy Maximum Per Injury HMO 60 Days Rehabilitation Therapies Speech Therapy Copayment HMO $0 Speech Therapy Maximum Per Illness/Injury HMO 60 Days Occupational Therapy Copayment HMO $0 Occupational Therapy Maximum Per Illness/Injury HMO 60 Days Chiropractic

4 Page 4 of 5 Chiropractic Authorized By Pmg Copayment HMO $0 Acupuncture Acupuncture Per Visit Copayment HMO $20 Durable Medical Equipment Durable Medical Equipment Copayment Pct HMO 20% Durable Medical Equipment Calendar Year Maximum HMO $5,000 Prosthesis Copayment HMO $0 Pediatric Asthma Equipment Pediatric Asthma Educ Prog Copayment HMO $20 Obstetrical Obstetrical Copayment HMO $20 Obstetrical Consultation Copayment HMO $20 Family Planning Copayment HMO $0 Abortion Copayment HMO $150 Sterilization/infertility Tubal Ligation Copayment HMO $150 Vasectomy Copayment HMO $50 Diagnosis & Testing For Infert P HMO 50% Home Health Care Home Health Per Visit Copayment HMO $0 Home Health Maximum HMO 100 Visits Hospice Care Hospice Copayment HMO $0 Bereavement Counseling Bereavement Pcp Copayment HMO $0 Mental Health Parity Inpatient Hospital-nervous/menta Inpatient Copayment Per Day HMO $100 Inpatient Psychiatric Calendar Year Maximum HMO 30 Days Outpatient Nervous/Mental Outpatient Nervous/Mental Copayment HMO $20 Outpatient Pscyh Maximum Vis Per Day HMO 1 Visit Outpatient Nervous/Mental Calendar Year Maximum HMO 20 Visits Professional Nervous/Mental HMO $35 Copayment HMO 1 Visit Maximum Per Day HMO 30 Visits Maximum Per Calendar Year Inpatient Substance Abuse Drug Rider Provider Network Benefit Details Action Drug Rider Coverage Brand Name Retail Copayment All $25 Brand Name Mail Order Copayment All $50

5 Page 5 of 5 Generic Retail Copayment All $10 Generic Mail Order Copayment All $10 Rx Mail Order Supply Maximum All 90 Days Rx Retail Supply Maximum All 30 Days Rx Non-formulary Retail Copayment All $40 Rx Non Formulary Brand Name M/o Copayment All $80 Rx Self-admin Inject Retail Copa All 20% Rx Self-admin Inject M/o Copayment All 20% Self-admin Inj Retail Copayment Maximum All $100 Self-admin Inject M/o Copayment Maximum All $200 Benefit Disclaimers This information does not pre-authorize payment. In order to receive benefits, the member must be covered at the time of service. The benefits information shown is not all-inclusive. It is limited to some coverage highlights. Other terms and limitations may apply even though such provisions are not indicated on this Web site. All claims are subject to medical review according to the information submitted by the provider of the service and are subject to benefit maximums and other terms of the member's contract. Please refer to the applicable benefit agreements to determine the appropriate payment amounts and any limitations or exclusions. If this is HMO coverage, benefits must be authorized by the member's assigned medical group. For groups subject to mental health parity legislation (AB88), mental health and substance abuse services are not subject to medical group referral or medical group authorization, but may require prior authorization from Anthem Blue Cross to the extent these services are covered under the member's plan.