Transaction ID: 3367147751

Transaction Date: Dec 31, 2015 5:31 pm

Customer ID: 471190

FONTAINE, MARTIN E Subscriber

MEMBER ID CPR708A54925
DOB Jun 17, 1952
GENDER Male
PLAN / COVERAGE DATE Oct 01, 2009 - Jan 01, 2016
DATE OF SERVICE Dec 31, 2015

Subscriber Information
5332 VENTURA CANYON AVE.
VAN NUYS, CA 91401
MEMBER ID CPR708A54925

CONTRACT CODE / CASE NUMBER C866

GROUP NUMBER CB070D
PLAN SPONSOR NAME PERCHOICE-CALPERS CA REGION

II (LA)
PLAN NAME PERCHOICE-CALPERS CA REGION II (LA)
PLAN NUMBER 040

Plan / Product Information

ACTIVE COVERAGE

EMPLOYEE AND SPOUSE

Service Types

INSURANCE TYPE

Preferred Provider Organization (PPO)

Health Benefit Plan Coverage

PLAN / PRODUCT

PRUDENT BUYER INCENTIVE

Payer Details
PAYER ANTHEM BLUE CROSS
PAYER ID 040

Other or Additional Payers

No Additional Payer Information

Provider Details
REQUESTING PROVIDER

NAME PINER
NPI 1821139601

Benefit Disclaimer
UNLESS OTHERWISE REQUIRED BY STATE LAW, THIS NOTICE IS NOT A GUARANTEE OF PAYMENT. BENEFITS ARE SUBJECT TO ALL
CONTRACT LIMITATIONS AND THE MEMBERS ELIGIBILITY STATUS ON THE DATE OF SERVICE. FOR ANY QUESTIONS PLEASE CALL PHONE
NUMBER ON BACK OF MEMBERS CARD.

Coverage and Benefits Information

Durable Medical Equipment Purchase - 12

Co-Insurance - Durable Medical Equipment Purchase
IN NETWORK

INDIVIDUAL

BENEFIT DATE

20 %

Jan 01, 2015 - Dec 31, 2015

AUTH REQUIRED UNKNOWN: CANNOT DETERMINE IF

THIS BENEFIT REQUIRES AN AUTHORIZATION.
DURABLE MEDICAL PAY

NAME UTILIZATION MANAGEMENT

TYPE Utilization Management Organization

P: 800-451-6780
OUT OF NETWORK

BENEFIT DATE

INDIVIDUAL
Jan 01, 2015 - Dec 31, 2015

AUTH REQUIRED UNKNOWN: CANNOT DETERMINE IF

THIS BENEFIT REQUIRES AN AUTHORIZATION.

40 %

Health Benefit Plan Coverage - 30

ACTIVE COVERAGE

EMPLOYEE AND SPOUSE

INSURANCE TYPE

Preferred Provider Organization (PPO)

PLAN / PRODUCT

PRUDENT BUYER INCENTIVE

Deductible - Health Benefit Plan Coverage

INDIVIDUAL

BENEFIT DATE

Jan 01, 2015 - Dec 31, 2015

$500.00
$0.00

Calendar Year

$1,000.00
$0.00

Calendar Year

$3,000.00
$0.00

Calendar Year

$6,000.00
$1,628.04

Calendar Year

Remaining

NETWORK NOT APPLICABLE

The Lesser of the individual or family deductible remaining
amount applies

FAMILY

BENEFIT DATE

Jan 01, 2015 - Dec 31, 2015

Remaining

NETWORK NOT APPLICABLE

The Lesser of the individual or family deductible remaining
amount applies

Out of Pocket (Stop Loss) - Health Benefit Plan Coverage

IN NETWORK

INDIVIDUAL

BENEFIT DATE

Jan 01, 2015 - Dec 31, 2015

Remaining

EXCLUDES DEDUCTIBLE AND COPAYMENTS

IN NETWORK

FAMILY

BENEFIT DATE

Jan 01, 2015 - Dec 31, 2015

EXCLUDES DEDUCTIBLE AND COPAYMENTS

Remaining