go with ^ Providence OptionPLUS HMO plan Access+ HMO plan Effective January 1, 2014

Transcription

1 go with ^ Providence OptionPLUS HMO plan Access+ HMO plan Effective January 1, 2014

2 Go with the plan that s right for you When you go with Blue Shield, you re on your way to quality health coverage, large provider networks, and a wide range of proven programs and services that help you get the most value from your coverage. In this booklet, you ll find the information you need to choose the right health plan for you and your family, including: lan benefits and features P How to find a doctor Additional programs and services available to Blue Shield members Get health plan information anytime, anywhere! From a smartphone members can check plan coverage, download their Blue Shield member ID card, get directions to the nearest urgent care center, and more. Just enter blueshieldca.com into the mobile browser. Our Member Center gives Blue Shield members instant access to their entire family s Blue Shield health coverage information from one account. Just go to blueshieldca.com/providence and select Log in. To learn more about Blue Shield through inspiring stories shared by our members, visit blueshieldca.com/memberstories. ii Blue Shield of California

3 Blue Shield is driven to offering you the right choices for your healthcare coverage Plan choices During the 2014 open enrollment period, Providence is offering two HMO plans: Providence OptionPLUS HMO plan and the Blue Shield Access+ HMO plan. Both HMO plans offer the same comprehensive Blue Shield benefits and value-added programs and services. With both plans you ll need to select your Personal Physician (primary care physician), who is responsible for the overall coordination of your care. You also have the option to self-refer to a specialist within your Personal Physician s medical group or Independent Practice Association (IPA) for a higher copayment using the Access+ Specialist* referral feature. The difference between the plans is the provider network. If you enroll in the Providence OptionPLUS HMO plan, you will have access to a smaller, specially selected network of Providence-affiliated medical groups and affiliated Personal Physicians and specialists than are available in the Access+ HMO plan. Below is a list of the Providence Southern California acute care hospitals that are also included in the Providence OptionPLUS HMO network: Providence Little Company of Mary Medical Center Torrance Providence Little Company of Mary Medical Center San Pedro Providence Holy Cross Medical Center Providence Tarzana Medical Center Providence Saint Joseph Medical Center Enrolling in the Blue Shield Access+ HMO or Providence OptionPLUS HMO plan When you enroll in either of the HMO plans for the first time, you will need to select your Personal Physician (primary care physician), who will be responsible for the overall coordination of your care, for yourself and your enrolled dependents. You have the option to choose a different Personal Physician and medical group for each enrolled family member. To find out if your doctor is in the Access+ HMO network, you can search online by following the steps on page 4. If you do not select a Personal Physician at the time of enrollment, Blue Shield will automatically assign a Personal Physician to you and your enrolled family members. You can change your Personal Physician by calling Blue Shield Member Services at (888) * If your personal physician participates in our access+ specialist program, you may go directly to a specialist in your personal physician s medical group or ipa without a referral, for a slightly higher copayment. Medical groups and ipas that participate in the access+ specialist program are designated with an a+ in our online and printed directories and on your blue shield member id card. team your team, your answers Open enrollment often brings up lots of questions about health plans and benefits. If you have questions, we ve got answers. Team Shield is your dedicated team of experts ready to help you get the right answers, right away. If you don t understand particular aspects of your medical coverage, or how to access all the benefits of your health plan, you can go online and post a question. We ll try to find the answers when you need them. Connect with Team Shield on Facebook or on 1

4 Behavioral health benefits The behavioral health benefits for the Blue Shield Access+ and Providence OptionPLUS HMO plans include inpatient and outpatient mental health and substance abuse care for issues such as: Depression Alcohol/drug abuse Mental illness Marriage and family counseling The services are provided by Blue Shield s mental health service administrator (MHSA) network. HMO members only have access to MHSA network providers. Care away from home Through the BlueCard Program, Blue Shield Access+ and Providence OptionPLUS HMO members can access emergency and urgent care services across the country and around the world. You can receive urgent care services from any provider; however, using the BlueCard Program can be more cost-effective and eliminate the need for you to pay for the services when they are rendered and submit a claim for reimbursement. You can locate a BlueCard provider at any time by calling (800) 810-BLUE or by going to the Find a Provider section of blueshieldca.com. The Away From Home Care program gives students, long-term travelers, workers on extended out-of-state assignments, and families living apart the convenience and flexibility of coverage for extended periods across the country. To learn more about Away From Home Care and whether your family is eligible, call your Blue Shield Member Services team at (888) Please note that Away From Home Care is not available in all areas and states, and benefits from the host plan may differ from the Access+ HMO or Providence OptionPLUS HMO plan. A website designed just for you! You have convenient 24-hour access to information about your health benefits at blueshieldca.com/providence. Here you can find a wide range of resources in one centralized location, including: Medical Benefits Learn about your medical plan features and benefits. Find a Provider Search for doctors and hospitals easily. NurseHelp 24/7 SM Get health advice from a registered nurse day or night. Programs and Services Find information on programs and services including prenatal and condition management. Visit blueshieldca.com/providence today! 2 Blue Shield of California

5 Providence OptionPLUS HMO plan and Access+ HMO plan benefits To learn more about these plans, please see the benefit summaries that begin on page 7. Providence OptionPLUS HMO plan and Access+ HMO plan Annual deductible None Annual out-of-pocket maximum or copayment maximum $1,500 per individual/$4,500 per family Member copayment Physician office visit Specialist office visit $15 per physician and specialist office visit $30 per Access+ Specialist visit* Preventive health benefits No charge Pregnancy and maternity care benefits No charge Outpatient X-ray, pathology, and laboratory No charge Hospital care (inpatient non-emergency facility services) Rehabilitation benefits (physical, occupational and respiratory therapy) Emergency room services (not resulting in admission) No charge at a Providence Health facility 20% per admission for all other facilities $150 per visit Mental health and substance abuse (outpatient physician visit) * To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by an MHSA network participating provider. Prenatal and postnatal physician office visits. For inpatient hospital services, see Hospitalization Services on the benefit summary in the back of this booklet. blueshieldca.com/providence 3

6 Find a network provider Search for a network provider online It s fast and easy to find a network provider online: Go to blueshieldca.com/providence. Select Find a Provider. Choose the type of provider you would like to search for. Find out your provider s quality of care rankings You can easily access quality scores, efficiency indicators, patient satisfaction scores, and cost information for many individual physicians, HMO medical groups, and hospitals. To see a provider s performance profile, simply click on the name of the doctor, HMO medical group, or hospital from your search results. How to find a Personal Physician (Primary Care Physician) Go to blueshieldca.com/providence and choose Find a Provider. Follow the instructions listed under the Access+ HMO or Providence OptionPLUS HMO plan. If you don t have access to the Internet or need help, simply contact your dedicated Blue Shield Member Services team at (888) for personal assistance or to request a provider directory. 6 Blue Shield of California

7 Your green light to added benefits, programs, and services As a member, you can find more information about these programs by going to blueshieldca.com/providence and selecting Log in. If you don t have a username and password, you can select Register for an online account. NurseHelp 24/7 Speak with registered nurses anytime, day or night, and get answers to your health-related questions, or go online to have a one-on-one personal chat with a registered nurse anytime. The NurseHelp 24/7 SM phone number is conveniently located on the back of your member ID card. LifeReferrals 24/7 Call anytime to talk with a team of experienced professionals ready to assist you with personal, family, and work issues. Get referrals for three face-to-face visits (in a six-month period) with a licensed therapist at no cost to you (available only in California). Telephonic counseling sessions with a licensed therapist are available for members outside of California. The LifeReferrals 24/7 SM phone number is located on the back of your member ID card. Prenatal Program This program gives expectant parents 24/7 access to experienced maternity nurses as well as prenatal information including a popular pregnancy or parenting book at no additional cost. Some materials are also available in Spanish. Condition management programs These programs offer nurse support as well as education and selfmanagement tools for members with asthma, diabetes, coronary artery disease, heart failure, and chronic obstructive pulmonary disease. Wellness discount programs Blue Shield offers a variety of member discounts on popular weight loss, fitness, vision, and health and wellness programs 1 that can help you save money and get healthier. 24 Hour Fitness Enjoy waived enrollment, processing, and initiation fees and discounts on monthly membership dues. Weight Watchers Get discounts on three- and 12-month subscriptions, monthly passes, and at-home kits. ClubSport and Renaissance ClubSport Obtain a 60% discount on enrollments when joining with a monthto-month agreement. Enrollment fees are waived when joining with a 12-month agreement. (There is a one-time $25 processing fee when you enroll.) Alternative Care Discount Program Get 25% off usual and customary fees for acupuncture, massage therapy, and chiropractic services, plus get discounts on health and wellness products, with free shipping on most items. Discount Provider Network 2 Take 20% off the published retail prices when you use a participating provider in the Discount Vision Program network for exams, frames, lenses, and more. MESVision Optics Take advantage of competitive prices on contact lenses, 3 sunglasses, readers, and eyecare accessories, with free shipping on orders over $50. QualSight LASIK Save on LASIK surgery at more than 45 surgery centers in California. Services include pre-screening, a pre-operative exam, and postoperative visits. NVISION Laser Eye Centers Receive a 15% discount on LASIK surgery from experienced surgeons with offices in Southern California and Sacramento. My2020EyesDirect Get a 20% discount on prescription eyeglasses, sunglasses, and readers. 3 blueshieldca.com/providence 5

8 1 These discount program services are not a covered benefit of Blue Shield health plans, and none of the terms or conditions of Blue Shield health plans apply. Discount program services are available to all members with a Blue Shield medical, dental, vision, or life insurance plan. The networks of practitioners and facilities in the discount programs are managed by the external program administrators identified below, including any screening and credentialing of providers. Blue Shield does not review the services provided by discount program providers for medical necessity or efficacy, nor does Blue Shield make any recommendations, representations, claims, or guarantees regarding the practitioners, their availability, fees, services, or products. Some services offered through the discount program may already be included as part of the Blue Shield plan covered benefits. Members should access those covered services prior to using the discount program. Members who are not satisfied with products or services received from the discount program may use Blue Shield s grievance process described in the Grievance Process section of the Evidence of Coverage. Blue Shield reserves the right to terminate this program at any time without notice. Discount programs administered by or arranged through the following independent companies: Alternative Care Discount Program American Specialty Health Systems, Inc. and American Specialty Health Networks, Inc. Discount Provider Network and MESVisionOptics.com MESVision Weight control Weight Watchers North America Fitness facilities 24 Hour Fitness, ClubSport, and Renaissance ClubSport LASIK Laser Eye Care of California, LLC; QualSight, Inc.; and NVISION Laser Eye Centers My2020EyesDirect.com Advanced Digital Eyewear Inc. Note: No genetic information, including family medical history, is gathered, shared, or used from these programs. 2 The Discount Provider Network is available throughout California. Coverage in other states may be limited. Find participating providers by going to blueshieldca.com/fap. 3 Requires a prescription from your doctor or licensed optical professional. 6 Blue Shield of California

9 Review benefit summaries Providence OptionPLUS HMO Plan Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Effective January 1, 2014 Calendar Year Facility Deductible None Calendar Year Copayment Maximum (For many covered services) $1,500 per Individual / $4,500 per Family LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services) Outpatient X-ray, pathology and laboratory Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) Access+ Specialist SM Benefits 2 Office visit, Examination or Other Consultation (Self-referred office visits and consultations $30 per visit only) Preventive Health Benefits Preventive Health Services (As required by applicable federal and California law.) OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery Center 3 Outpatient surgery in a hospital Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient Physician Services Inpatient Non-emergency Providence Health Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care) Inpatient Non-emergency Facility Services (Semi-private room and board, and medicallynecessary Services and supplies, including Subacute Care) 20% per admission Inpatient Medically Necessary skilled nursing Services including Subacute Care at a Providence Health Facility 4 Inpatient Medically Necessary skilled nursing Services including Subacute Care 4, 5 20% per admission EMERGENCY HEALTH COVERAGE Emergency room facility services (The ER copayment does not apply if the member is directly $150 per visit admitted to the hospital for inpatient services) Emergency room Physician Services AMBULANCE SERVICES Emergency or authorized transport blueshieldca.com/providence 7

10 Covered Services PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits Member Copayment Provided by Express Scripts (800) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (Separate office visit copay may apply) Orthotic equipment and devices (Separate office visit copay may apply) DURABLE MEDICAL EQUIPMENT Breast pump Other Durable Medical Equipment (member share is based upon allowed charges) MENTAL HEALTH SERVICES (PSYCHIATRIC) 6 Inpatient Hospital Services Outpatient Mental Health Services CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 7 Please see footnote 9 Chemical dependency and substance abuse services Not Covered HOME HEALTH SERVICES Home health care agency Services (up to 100 visits per Calendar Year) Medical supplies (See "Prescription Drug Coverage" for specialty drugs) OTHER Hospice Program Benefits Routine home care Inpatient Respite Care 24-hour Continuous Home Care General Inpatient care Pregnancy and Maternity Care Benefits Prenatal and postnatal Physician office visits (For inpatient hospital services, see "Hospitalization Services.") Family Planning and Infertility Benefits Counseling and consulting 8 Infertility Services (member share is based upon allowed charges) 50% (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT). Tubal ligation Not Covered Elective abortion Not Covered Vasectomy Not Covered Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Office location (Copayment applies to all places of services, including professional and facility settings) Speech Therapy Benefits Office Visit - Services by licensed speech therapists (Copayment applies to all places of services, including professional and facility settings) Diabetes Care Benefits Devices, equipment, and non-testing supplies (member share is based upon allowed charges) Diabetes self-management training (by a registered dietician or registered nurse that are certified diabetes educators) Hearing Aid Benefits Hearing examination Hearing aid and ancillary equipment (Plan payment up to maximum of $5,000 per member every 24 months) Urgent Care Benefits (BlueCard Program) Urgent Services outside your Personal Physician Service Area Optional Benefits 1 Optional dental, vision, hearing aid, infertility, substance abuse, chiropractic or chiropractic and acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. 8 Blue Shield of California

11 1 Copayments/Coinsurance marked with this footnote do not accrue to the calendar-year copayment maximum. Copayments/Coinsurance and charges for services not accruing to the member's calendar-year copayment maximum continue to be the member's responsibility after the calendar-year copayment maximum is reached. This amount could be substantial. Please refer to the Evidence of Coverage and the Plan Contract for exact terms and conditions of coverage. 2 To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by a MHSA network participating provider. 3 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 4 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan deductible has been met. 5 Skilled nursing services are limited to 100 preauthorized days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 6 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage and Plan Contract. 7 Inpatient Services which are Medically Necessary to treat the acute medical complications of detoxification are covered under the medical benefits; see hospitalization services for benefit details. Services for acute medical complications of detoxification are accessed through Blue Shield using Blue Shield HMO providers. 8 Includes insertion of IUD, as well as injectable and implantable contraceptives for women. 9 Optional substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as "Additional Substance Abuse Treatment Benefits." Plan designs may be modified to ensure compliance with state and federal requirements. A15818 (1/14) ML BH BH ML BH blueshieldca.com/providence 9

12 Providence OptionPLUS HMO plan Substance Abuse Treatment Benefits Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix) How the Plan Works In addition to the benefits listed in the Benefit Summary, your health plan also covers inpatient hospital and professional (physician) services for substance abuse treatment and rehabilitation provided via hospitalization or partial hospitalization/day treatment. 1 All services must be medically necessary. Blue Shield of California has contracted with a Mental Health Service Administrator (MHSA), a licensed specialized health care service plan, to administer and deliver these services from MHSA participating providers. The MHSA is only the administrator for participating providers. Blue Shield of California does not provide benefits for services provided by non-participating providers. Coverage Details Residential care is not covered. Covered Services Member Copayment 2 MHSA Participating Provider Inpatient Hospitalization Professional (Physician) Services - Inpatient and Outpatient Physician Visit Partial Hospitalization/Day Treatment Physician Visit Copay Applies Ambulatory Surgery Copay Applies 1. Except for emergencies, benefits are covered only when pre-authorized by the MHSA. 2. Please refer to the Medical Benefit Summary for applicable copayment responsibility. This document is only a summary for informational purposes. It is not a contract. Please refer to the Plan Contract and Evidence of Coverage for the exact terms and conditions of coverage. 10 Blue Shield of California

13 Access+ HMO Plan Benefit Summary (For groups of 300 and above) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Effective January 1, 2014 Calendar Year Facility Deductible None Calendar Year Copayment Maximum (For many covered services) $1,500 per Individual / $4,500 per Family LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits (Note: A woman may self-refer to an OB/GYN or family practice physician in her Personal Physician's medical group or IPA for OB/GYN services) Outpatient X-ray, pathology and laboratory Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) Access+ Specialist SM Benefits 2 Office visit, Examination or Other Consultation (Self-referred office visits and consultations $30 per visit only) Preventive Health Benefits Preventive Health Services (As required by applicable federal and California law.) OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an Ambulatory Surgery Center 3 Outpatient surgery in a hospital Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under "Rehabilitation Benefits" and "Speech Therapy Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient Physician Services Inpatient Non-emergency Providence Health Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care) Inpatient Non-emergency Facility Services (Semi-private room and board, and medicallynecessary Services and supplies, including Subacute Care) Inpatient Medically Necessary skilled nursing Services including Subacute Care at a Providence Health Facility 4 20% per admission Inpatient Medically Necessary skilled nursing Services including Subacute Care 4, 5 20% per admission EMERGENCY HEALTH COVERAGE Emergency room facility services (The ER copayment does not apply if the member is directly $150 per visit admitted to the hospital for inpatient services) Emergency room Physician Services AMBULANCE SERVICES Emergency or authorized transport PRESCRIPTION DRUG COVERAGE Outpatient Prescription Drug Benefits Provided by Express Scripts (800) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (Separate office visit copay may apply) Orthotic equipment and devices (Separate office visit copay may apply) blueshieldca.com/providence 11

14 Covered Services Member Copayment DURABLE MEDICAL EQUIPMENT Breast pump Other Durable Medical Equipment (member share is based upon allowed charges) MENTAL HEALTH SERVICES (PSYCHIATRIC) 6 Inpatient Hospital Services Outpatient Mental Health Services CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 7 Please see footnote 9 Chemical dependency and substance abuse services Not Covered HOME HEALTH SERVICES Home health care agency Services (up to 100 visits per Calendar Year) Medical supplies (See "Prescription Drug Coverage" for specialty drugs) OTHER Hospice Program Benefits Routine home care Inpatient Respite Care 24-hour Continuous Home Care General Inpatient care Pregnancy and Maternity Care Benefits Prenatal and postnatal Physician office visits (For inpatient hospital services, see "Hospitalization Services.") Family Planning and Infertility Benefits Counseling and consulting 8 Infertility Services (member share is based upon allowed charges) 50% (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT). Tubal ligation Not Covered Elective abortion Not Covered Vasectomy Not Covered Rehabilitation Benefits (Physical, Occupational and Respiratory Therapy) Office location (Copayment applies to all places of services, including professional and facility settings) Speech Therapy Benefits Office Visit - Services by licensed speech therapists (Copayment applies to all places of services, including professional and facility settings) Diabetes Care Benefits Devices, equipment, and non-testing supplies (member share is based upon allowed charges) Diabetes self-management training (by a registered dietician or registered nurse that are certified diabetes educators) Hearing Aid Benefits Hearing examination Hearing aid and ancillary equipment (Plan payment up to maximum of $5,000 per member every 24 months) Urgent Care Benefits (BlueCard Program) Urgent Services outside your Personal Physician Service Area Optional Benefits 1 Optional dental, vision, hearing aid, infertility, substance abuse, chiropractic or chiropractic and acupuncture benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. 12 Blue Shield of California

15 1 Copayments/Coinsurance marked with this footnote do not accrue to the calendar-year copayment maximum. Copayments/Coinsurance and charges for services not accruing to the member's calendar-year copayment maximum continue to be the member's responsibility after the calendar-year copayment maximum is reached. This amount could be substantial. Please refer to the Evidence of Coverage and the Plan Contract for exact terms and conditions of coverage. 2 To use this option, members must select a personal physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+ Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health services must be provided by a MHSA network participating provider. 3 Participating Ambulatory Surgery Centers may not be available in all areas. Outpatient surgery Services may also be obtained from a Hospital or from an ambulatory surgery center that is affiliated with a Hospital, and paid according to the benefit under your health plan's Hospital Benefits. 4 For Plans with a facility deductible amount, services with a day or visit limit accrue to the calendar-year day or visit limit maximum regardless of whether the plan deductible has been met. 5 Skilled nursing services are limited to 100 preauthorized days during a calendar year except when received through a hospice program provided by a participating hospice agency. This 100 preauthorized day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities. 6 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating providers. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Evidence of Coverage and Plan Contract. 7 Inpatient Services which are Medically Necessary to treat the acute medical complications of detoxification are covered under the medical benefits; see hospitalization services for benefit details. Services for acute medical complications of detoxification are accessed through Blue Shield using Blue Shield HMO providers. 8 Includes insertion of IUD, as well as injectable and implantable contraceptives for women. 9 Optional substance abuse treatment benefits are available. If your employer purchased these benefits, a description of the benefit is attached hereto as "Additional Substance Abuse Treatment Benefits." Plan designs may be modified to ensure compliance with state and federal requirements. A15818 (1/14) ML BH BH ML blueshieldca.com/providence 13

16 Access+ HMO Plan Substance Abuse Treatment Benefits Attachment to Benefit Summary (Uniform Benefits and Coverage Matrix) How the Plan Works In addition to the benefits listed in the Benefit Summary, your health plan also covers inpatient hospital and professional (physician) services for substance abuse treatment and rehabilitation provided via hospitalization or partial hospitalization/day treatment. 1 All services must be medically necessary. Blue Shield of California has contracted with a Mental Health Service Administrator (MHSA), a licensed specialized health care service plan, to administer and deliver these services from MHSA participating providers. The MHSA is only the administrator for participating providers. Blue Shield of California does not provide benefits for services provided by non-participating providers. Coverage Details Residential care is not covered. Covered Services Member Copayment 2 MHSA Participating Provider Inpatient Hospitalization Professional (Physician) Services - Inpatient and Outpatient Physician Visit Partial Hospitalization/Day Treatment Physician Visit Copay Applies Ambulatory Surgery Copay Applies 1. Except for emergencies, benefits are covered only when pre-authorized by the MHSA. 2. Please refer to the Medical Benefit Summary for applicable copayment responsibility. This document is only a summary for informational purposes. It is not a contract. Please refer to the Plan Contract and Evidence of Coverage for the exact terms and conditions of coverage. 14 Blue Shield of California

17 Notice on the availability of language assistance services to accompany vital documents issued in English IMPORTANT: Can you read this letter? If not, we can have somebody help you read it. You may also be able to get this letter written in your language. For free help, please call right away at the Member/Customer Service telephone number on the back of your Blue Shield ID card, or (866) IMPORTANTE: Puede leer esta carta? Si no, podemos hacer que alguien le ayude a leerla. También puede recibir esta carta en su idioma. Para ayuda gratuita, por favor llame inmediatamente al teléfono de Servicios al miembro/cliente que se encuentra al reverso de su tarjeta de identificación de Blue Shield o al (866) (Spanish) 重 要 通 知 : 您 能 讀 懂 這 封 信 嗎? 如 果 不 能, 我 們 可 以 請 人 幫 您 閱 讀 這 封 信 也 可 以 用 您 所 講 的 語 言 書 寫 如 需 幫 助, 請 立 即 撥 打 登 列 在 您 的 Blue Shield ID 卡 背 面 上 的 會 員 / 客 戶 服 務 部 的 電 話, 或 者 撥 打 電 話 (Chinese) QUAN TRỌNG: Quý vị có thể đọc lá thư này không? Nếu không, chúng tôi có thể nhờ người giúp quý vị đọc thư. Quý vị cũng có thể nhận lá thư này được viết bằng ngôn ngữ của quý vị. Để được hỗ trợ miễn phí, vui lòng gọi ngay đến Ban Dịch vụ Hội viên/khách hàng theo số ở mặt sau thẻ ID Blue Shield của quý vị hoặc theo số (Vietnamese) blueshieldca.com/providence 15

18 notes 16 Blue Shield of California

19 notes blueshieldca.com/providence 17

20 Go with Blue Shield and get on the road to better health. For any questions, visit blueshieldca.com/ providence or call your dedicated Blue Shield Member Services team at (888) , from 7 a.m. to 7 p.m., Monday through Friday. Member confidentiality Blue Shield protects the confidentiality and privacy of your personal and health information, including medical information and individually identifiable information such as your name, address, telephone number, and Social Security number. To ensure this, Blue Shield requires a signed authorization form for you to access health information for your spouse or dependents over the age of 18. To request an authorization form, log in to blueshieldca.com and select My Health Plan. Click on Download Forms under Tools on the right side. Scroll down to Release of information and click on Personal and Health Information Release. If you don t have access to the Internet, or have questions about how Blue Shield protects your privacy and confidentiality, please call our Privacy Office directly at (888) Blue Shield of California is an independent member of the Blue Shield Association A37282-HMO-PRO (8/13)