benefit summary guide Group health plan information for small businesses with 1 to 50 eligible employees Effective January 1, 2014 blueshieldca.com
Healthcare coverage that works for your business With easy access to quality provider networks and a choice of 23 health plans in a simple, easy-tounderstand and affordable portfolio, Blue Shield is making it easier for you to choose health coverage for your employees. Inside this guide, you ll find detailed benefit charts to help you find the right Blue Shield plans for your small businesses. This guide describes the small group benefit plans available directly from Blue Shield for new and renewing customers. Blue Shield small group plans are also available through Covered California and are described in a separate guide. This guide details: The range of health plan options The specialty benefits products that complement our health plans. Legal information and a description of plan limitations and exclusions Introducing standardized levels of coverage beginning in 2014 Under the Affordable Care Act, four standardized levels of coverage are established. These are referred to as the metal levels: platinum, gold, silver and bronze. Each metal level of coverage is based on a different actuarial value*, which indicates the percentage of health costs that, for an average population, would be covered by that health plan. The actuarial value applicable to each of the four metals levels are: Platinum = 90% Gold = 80% Silver = 70% Bronze = 60% * The Department of Health & Human Services (HHS) recognizes that health plans need some flexibility in meeting the metal levels. Therefore, it finalized that a plan can meet a particular metal level if its actuarial value is within +/- 2 percentage points of the standard. For example, a silver plan may have an actuarial value between 68% and 72%. Metal Level Coverage to Blue Shield plan name key Platinum coverage = Ultimate plan Gold coverage = Preferred plan Silver coverage = Enhanced plan Bronze coverage = Basic plan For questions about the information in this guide, please contact your broker or Blue Shield representative today, or visit us online at blueshieldca.com/employer. ii Benefit Summary Guide
Table of contents Health plans PPO health plans PPO plans at a glance 2 Benefit summaries 4 HSA-eligible high-deductible health plans (HDHPs) HSA-HDHP plans at a glance 44 Benefit summaries 45 HMO health plans Full Network HMO and Exclusive Network HMO plans at a glance 60 Benefit summaries 63 Specialty benefits Dental PPO, INO, and HMO plans 112 Vision plans 126 Group term life (basic life) and accidental death and dismemberment (AD&D) insurance 130 General plan information Guaranteed-issue coverage 131 Principal plan limitations and exclusions 131 Maximum aggregate payment amount 133 Notice of confidentiality and privacy practices 134 Supplemental coverage Supplemental coverage at a glance 111 Additional infertility benefits 111 Benefit Summary Guide 1
PPO health plans The PPO plans at a glance Blue Shield PPO plans offer members the flexibility and simplicity of having direct access to the physicians and specialists in our PPO provider networks. Additional highlights include: Coverage for essential health benefits No charge for preventive care visits with participating providers Choice of accessing care from either participating or non-participating providers PPO provider networks Each Blue Shield PPO plan has a provider network associated with it, consisting of participating physicians, hospitals, and other providers. You can find out which providers are in each network by going to Find a Provider at blueshieldca.com/fap. The Basic Exclusive PPO plan for Small Business uses the Blue Shield of California Exclusive PPO Network and is available in certain California counties and cities (the service area ). The employer must be located and their eligible employees must live or work in the Exclusive PPO service area, which includes the following seven Southern California, eleven Northern California, and seven Central California counties: Southern California Imperial County Los Angeles County, except for ZIP codes 90704, 93510, 93532, 93534, 93535, 93536, 93539, 93543, 93544, 93550, 93551, 93552, 93553, 93584, 93586, 93590, 93591, and 93599 Orange County Riverside County, except for ZIP codes 92225, 92226, 92239, 92275, and 92539 San Bernardino County, except for ZIP codes 91759, 92252, 92256, 92267, 92268, 92277, 92278, 92284, 92285, 92286, 92304, 92305, 92309, 92310, 92314, 92315, 92317, 92321, 92322, 92323, 92325, 92326, 92327, 92332, 92333, 92338, 92341, 92342, 92347, 92352, 92356, 92358, 92364, 92365, 92366, 92368, 92372, 92378, 92382, 92385, 92386, 92391, 92395, 92397, 92398, 92407, 93523, 93562, and 93592 San Diego County, except for ZIP codes 91905, 91906, 91934, 91963, 91980, 91987, 92004, 92036, 92066, and 92086 Ventura County, except for ZIP codes 91307, 91358, 91359, 91360, 91361, 91362, 91377, 93020, 93021, 93040, 93042, 93062, 93063, 93064, 93065, 93094, and 93099 Northern California Alameda County Contra Costa County, except for ZIP codes 94525, 94530, 94547, 94564, 94569, 94572, 94801, 94802, 94803, 94804, 94805, 94806, 94807, 94808, 94820, and 94850 Marin County Nevada County, except for ZIP codes 95724, 95728, 95977, 96111, 96160, 96161, and 96162. Sacramento County, except for ZIP codes 95632, 95638, 95639, 95641, 95671, 95680, 95683, 95690, 95693, 95798, and 95799 San Francisco County Santa Clara County Santa Cruz County San Mateo County, except for ZIP codes 94018, 94019, 94020, 94021, 94028, 94037, 94038, 94060, and 94074 Sonoma County Yolo County Central California Butte County Fresno County Kern County, except for ZIP codes 93205, 93206, 93220, 93222, 93224, 93225, 93226, 93238, 93240, 93243, 93249, 93251, 93252, 93255, 93555, 93558, 93268, 93283, 93285, 93287, 93501, 93502, 93504, 93505, 93516, 93518, 93519, 93524, 93560, and 93596 Kings County Madera County San Luis Obispo County Stanislaus County 2 Benefit Summary Guide
Access to care and limitations Blue Shield PPO plans and member share-of-costs, like deductibles and copayments, vary based on the plan. Some services, like preventive care, are only covered when care is accessed from participating providers (providers contracted with Blue Shield). Preventive care is also covered prior to meeting the calendar-year medical deductible and with no member share-of-cost. Members who receive care from a Blue Shield PPO participating provider are responsible for meeting the applicable calendar-year medical deductible and copayment or coinsurance for the covered services, up to the calendar-year copayment maximum. Members who receive care from a non-participating provider are responsible for meeting the applicable calendar-year medical deductible and copayment or coinsurance for the covered services, as well as provider charges that exceed Blue Shield s allowable amount. Provider charges above Blue Shield s allowable amount do not accrue to the calendar year copayment maximum. Certain healthcare services may not be available in your area. You may be required to travel in excess of 30 minutes to access these services. Please see the General Plan Information section of this guide for information on benefit plan limitations and exclusions. The Exclusive network includes a subset of physicians, IPAs and Medical groups from our Full Network. Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 3
Ultimate Full PPO for Small Business 0 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This health plan uses the Full PPO provider network. DEDUCTIBLE Participating Providers 2 Providers 2 Non-Participating Calendar Year Medical Deductible (Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year medical deductibles.) Calendar Year Brand Drug Deductible Calendar Year Out-of-Pocket Maximum 1 (Includes the medical plan deductible. Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year out-of-pocket maximums.) LIFETIME BENEFIT MAXIMUM Covered Services PROFESSIONAL SERVICES Professional (Physician) Benefits Physician office visits Specialist office visits A45900 (1/14) $0 per individual / $0 per family None $2,500 per individual / $5,000 per family None $0 per individual / $0 per family $5,000 per individual / $10,000 per family Member Copayment Non- Participating Participating Providers 2 Providers 2 $10 per visit 40% $25 per visit 40% 10% 40% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging 3 (non-hospital based or affiliated) 10% 40% Outpatient diagnostic laboratory and pathology 3 (non-hospital based or 10% 40% affiliated) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 10% 40% Preventive Health Benefits Preventive health services 4 (as required by applicable federal and California law) 4 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 5 10% 40% 6 Outpatient surgery in a hospital 10% 40% 6 Outpatient services for treatment of illness or injury and necessary 10% 40% 6 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $100 per visit + 10% 40% 6 procedures utilizing nuclear medicine performed in a hospital 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging performed in a hospital 3 10% 40% 6 Outpatient diagnostic laboratory and pathology performed in a 10% 40% 6 hospital 3 Bariatric surgery 7 (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only) 10% 40% 6 An Independent Member of the Blue Shield Association 4 Benefit Summary Guide
HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 10% 40% Inpatient non-emergency facility services (semi-private room and board, and 10% 40% 8 medically-necessary services and supplies, including subacute care) Bariatric surgery 7 (prior authorization required; medically necessary surgery for weight loss, for morbid obesity only) 10% 40% 8 9, 10 Skilled Nursing Facility Benefits (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 10% 10% Skilled nursing unit of a hospital 10% 40% 8 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not $100 per visit + 10% $100 per visit + 10% apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 10% 10% admitted directly from the ER) Emergency room physician services 10% 10% Urgent care $10 per visit Not covered AMBULANCE SERVICES Emergency or authorized transport (ground or air) 10% 10% 11, 12, 13 PRESCRIPTION DRUG COVERAGE Participating Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 14 Pharmacy Medical Deductible) Non-Participating Pharmacy Generic drugs $5 per prescription Preferred brand drugs $30 per prescription Non-preferred brand drugs $50 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 14 Generic drugs $10 per prescription Preferred brand drugs $60 per prescription Non-preferred brand drugs $100 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are 30% per prescription covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Preferred Providers 2 Non-Preferred Providers 2 Prosthetic equipment and devices (separate office visit copayment may apply) 10% Orthotic equipment and devices (separate office visit copayment may apply) 10% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 18 MHSA Participating Providers 2 MHSA Non-Participating Providers 2 Inpatient hospital services (prior authorization is required) 10% 40% 8 Outpatient mental health services (some services may require prior authorization and facility charges) $10 per visit 40% Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 5
CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 18 Inpatient hospital services for medical acute detoxification (prior authorization is required) Outpatient substance abuse services (some services may require prior authorization and facility charges) Pediatric Vision Benefits Comprehensive Eye Exam 19 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) 10% 40% 8 $10 per visit HOME HEALTH SERVICES Preferred Providers 2 Non-Preferred Providers 2 Home health care agency services 9 (up to 100 prior authorized visits per 10% 15 calendar year) Home infusion/home intravenous injectable therapy and infusion 10% 15 nursing visits provided by a home infusion agency OTHER Hospice Program Benefits Routine home care 15 Inpatient respite care 15 24-hour continuous home care 15 Short-term inpatient care for pain and symptom management 15 Chiropractic Benefits 9 Chiropractic services (up to 12 visits per calendar year) 50% 1 40% 50% 1 (not subject to the Calendar Year Medical Deductible) Acupuncture Benefits Acupuncture by a licensed acupuncturist $25 per visit $25 per visit Acupuncture by a doctor of medicine $25 per visit 40% Rehabilitation Benefits Office location 10% 40% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visit: initial visit (for inpatient hospital services, see "Hospitalization Services) 40% Prenatal and preconception physician office visit: subsequent visits 10% 40% Postnatal physician office visits 10% 40% (for inpatient hospital services, see "Hospitalization Services) Family Planning Benefits 4, 16 Counseling and consulting Elective abortion 17 10% Tubal ligation 4 (not subject to the Calendar Year Medical Deductible) Vasectomy 17 10% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see 50% outpatient prescription drug benefits.) Diabetes self-management training (if billed by the provider, member is also responsible for an office visit copayment) $10 per visit 40% Care Outside of Plan Service Area (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental, vision, and infertility benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Up to $30 Maximum 6 Benefit Summary Guide
Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Up to $30 Maximum Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 20 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 21 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 22 35% Not covered Diabetes management referral Not covered 1 Amounts for services marked with this footnote that are paid by the member do not accrue to calendar year out-of-pocket maximum. Copayments, coinsurance and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage for additional details. 2 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of allowable amounts. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts. When members use non-participating providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield s allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. 3 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits. 4 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 5 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefits. 6 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 40% of this $350 per day, plus all charges in excess of $350. Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 7
7 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. 8 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 40% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum. 9 Services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. 10 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 11 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 12 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 13 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 14 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 15 Services from non-participating providers, home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 16 Includes insertion of IUD as well as injectable contraceptives for women. 17 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Non-participating provider facilities are not covered under this benefit. 18 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 19 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 20 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 21 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 22 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 8 Benefit Summary Guide
Ultimate Full PPO for Small Business 150 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This health plan uses the Full PPO provider network. DEDUCTIBLE Participating Providers 2 Providers 2 Non-Participating Calendar Year Medical Deductible (Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year medical deductibles.) Calendar Year Brand Drug Deductible Calendar Year Out-of-Pocket Maximum 1 (Includes the medical plan deductible. Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year out-of-pocket maximums.) LIFETIME BENEFIT MAXIMUM Covered Services PROFESSIONAL SERVICES Professional (Physician) Benefits Physician office visits Specialist office visits A45901 (1/14) $150 per individual / $300 per family None $3,000 per individual / $6,000 per family None $300 per individual / $600 per family $8,000 per individual / $16,000 per family Member Copayment Non- Participating Participating Providers 2 Providers 2 $15 per visit 40% $30 per visit 40% 10% 40% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging 3 (non-hospital based or affiliated) 10% 40% Outpatient diagnostic laboratory and pathology 3 (non-hospital based or 10% 40% affiliated) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 10% 40% Preventive Health Benefits Preventive health services 4 (as required by applicable federal and California law) 4 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 5 10% 40% 6 Outpatient surgery in a hospital 10% 40% 6 Outpatient services for treatment of illness or injury and necessary 10% 40% 6 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $100 per visit + 10% 40% 6 procedures utilizing nuclear medicine performed in a hospital 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging performed in a hospital 3 10% 40% 6 Outpatient diagnostic laboratory and pathology performed in a 10% 40% 6 hospital 3 Bariatric surgery 7 (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only) 10% 40% 6 An Independent Member of the Blue Shield Association Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 9
HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 10% 40% Inpatient non-emergency facility services (semi-private room and board, and 10% 40% 8 medically-necessary services and supplies, including subacute care) Bariatric surgery 7 (prior authorization required; medically necessary surgery for weight 10% 40% 8 loss, for morbid obesity only) 9, 10 Skilled Nursing Facility Benefits (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 10% 10% Skilled nursing unit of a hospital 10% 40% 8 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not $100 per visit + 10% $100 per visit + 10% apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 10% 10% admitted directly from the ER) Emergency room physician services 10% 10% Urgent care $15 per visit Not covered AMBULANCE SERVICES Emergency or authorized transport (ground or air) 10% 10% 11, 12, 13 PRESCRIPTION DRUG COVERAGE Participating Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 14 Pharmacy Medical Deductible) Non-Participating Pharmacy Generic drugs $5 per prescription Preferred brand drugs $30 per prescription Non-preferred brand drugs $50 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 14 Generic drugs $10 per prescription Preferred brand drugs $60 per prescription Non-preferred brand drugs $100 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are 30% per prescription covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Preferred Providers 2 Non-Preferred Providers 2 Prosthetic equipment and devices (separate office visit copayment may apply) 10% Orthotic equipment and devices (separate office visit copayment may apply) 10% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 18 MHSA Participating Providers 2 MHSA Non-Participating Providers 2 Inpatient hospital services (prior authorization is required) 10% 40% 8 Outpatient mental health services (some services may require prior authorization and facility charges) $15 per visit 40% 10 Benefit Summary Guide
CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 18 Inpatient hospital services for medical acute detoxification (prior authorization is required) Outpatient substance abuse services (some services may require prior authorization and facility charges) Pediatric Vision Benefits Comprehensive Eye Exam 19 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) 10% 40% 8 $15 per visit HOME HEALTH SERVICES Preferred Providers 2 Non-Preferred Providers 2 Home health care agency services 9 (up to 100 prior authorized visits per 10% 15 calendar year) Home infusion/home intravenous injectable therapy and infusion 10% 15 nursing visits provided by a home infusion agency OTHER Hospice Program Benefits Routine home care 15 Inpatient respite care 15 24-hour continuous home care 15 Short-term inpatient care for pain and symptom management 15 Chiropractic Benefits 9 Chiropractic services (up to 12 visits per calendar year) 50% 1 40% 50% 1 (not subject to the Calendar Year Medical Deductible) Acupuncture Benefits Acupuncture by a licensed acupuncturist $25 per visit $25 per visit Acupuncture by a doctor of medicine $25 per visit 40% Rehabilitation Benefits Office location 10% 40% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visit: initial visit (for inpatient hospital services, see "Hospitalization Services 40% Prenatal and preconception physician office visit: subsequent visits 10% 40% Postnatal physician office visits 10% 40% (for inpatient hospital services, see "Hospitalization Services) Family Planning Benefits 4, 16 Counseling and consulting Elective abortion 17 10% Tubal ligation 4 (not subject to the Calendar Year Medical Deductible) Vasectomy 17 10% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see 50% outpatient prescription drug benefits.) Diabetes self-management training (if billed by the provider, member is also responsible for an office visit copayment) $15 per visit 40% Care Outside of Plan Service Area (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental, vision, and infertility benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Up to $30 Maximum Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 11
Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Up to $30 Maximum Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 20 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 21 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 22 35% Not covered Diabetes management referral Not covered 1 Amounts for services marked with this footnote that are paid by the member do not accrue to calendar year out-of-pocket maximum. Copayments, coinsurance and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage for additional details. 2 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of allowable amounts. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts. When members use non-participating providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield s allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. 3 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits. 4 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 5 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefits. 6 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 40% of this $350 per day, plus all charges in excess of $350. 12 Benefit Summary Guide
7 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. 8 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 40% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum. 9 Services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. 10 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 11 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 12 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 13 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 14 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 15 Services from non-participating providers, home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 16 Includes insertion of IUD as well as injectable contraceptives for women. 17 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Non-participating provider facilities are not covered under this benefit. 18 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 19 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 20 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 21 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 22 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 13
Preferred Full PPO for Small Business 0 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This health plan uses the Full PPO provider network. DEDUCTIBLE Participating Providers 2 Providers 2 Non-Participating Calendar Year Medical Deductible (Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year medical deductibles.) Calendar Year Brand Drug Deductible Calendar Year Out-of-Pocket Maximum 1 (Includes the medical plan deductible. Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year out-of-pocket maximums.) LIFETIME BENEFIT MAXIMUM Covered Services PROFESSIONAL SERVICES Professional (Physician) Benefits Physician office visits Specialist office visits A45903 (1/14) $0 per individual / $0 per family None $5,000 per individual / $10,000 per family None $0 per individual / $0 per family $10,000 per individual / $20,000 per family Member Copayment Non-Participating Participating Providers 2 Providers 2 $20 per visit 40% $45 per visit 40% 25% 40% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging 3 (non-hospital based or affiliated) 25% 40% Outpatient diagnostic laboratory and pathology 3 25% 40% (non-hospital based or affiliated) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 25% 40% Preventive Health Benefits Preventive health services 4 (as required by applicable federal and California law) 4 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 5 25% 40% 6 Outpatient surgery in a hospital 25% 40% 6 Outpatient services for treatment of illness or injury and necessary 25% 40% 6 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $100 per visit + 25% 40% 6 procedures utilizing nuclear medicine performed in a hospital 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging performed in a hospital 3 25% 40% 6 Outpatient diagnostic laboratory and pathology performed in a 25% 40% 6 hospital 3 Bariatric surgery 7 (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only) 25% 40% 6 An Independent Member of the Blue Shield Association 14 Benefit Summary Guide
HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 25% 40% Inpatient non-emergency facility services (semi-private room and board, and 25% 40% 8 medically-necessary services and supplies, including subacute care) Bariatric surgery 7 (prior authorization required; medically necessary surgery for weight 25% 40% 8 loss, for morbid obesity only) 9, 10 Skilled Nursing Facility Benefits (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 25% 25% Skilled nursing unit of a hospital 25% 40% 8 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not $100 per visit + 25% $100 per visit + 25% apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 25% 25% admitted directly from the ER) Emergency room physician services 25% 25% Urgent care $20 per visit Not covered AMBULANCE SERVICES Emergency or authorized transport (ground or air) 25% 25% 11, 12, 13 PRESCRIPTION DRUG COVERAGE Participating Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 14 Pharmacy Non-Participating Pharmacy Generic drugs $15 per prescription Preferred brand drugs $40 per prescription Non-preferred brand drugs $60 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 14 Generic drugs $30 per prescription Preferred brand drugs $80 per prescription Non-preferred brand drugs $120 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are 30% per prescription covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Preferred Providers 2 Non-Preferred Providers 2 Prosthetic equipment and devices (separate office visit copayment may apply) 25% Orthotic equipment and devices (separate office visit copayment may apply) 25% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 18 MHSA Participating Providers 2 MHSA Non-Participating Providers 2 Inpatient hospital services (prior authorization is required) 25% 40% 8 Outpatient mental health services (some services may require prior authorization and facility charges) $20 per visit 40% Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 15
CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 18 Inpatient hospital services for medical acute detoxification (prior authorization is required) Outpatient substance abuse services (some services may require prior authorization and facility charges) Pediatric Vision Benefits Comprehensive Eye Exam 19 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) 25% 40% 8 $20 per visit HOME HEALTH SERVICES Preferred Providers 2 Non-Preferred Providers 2 Home health care agency services 9 (up to 100 prior authorized visits per 25% 15 calendar year) Home infusion/home intravenous injectable therapy and infusion 25% 15 nursing visits provided by a home infusion agency OTHER Hospice Program Benefits Routine home care 15 Inpatient respite care 15 24-hour continuous home care 15 Short-term inpatient care for pain and symptom management 15 Chiropractic Benefits 9 Chiropractic services (up to 12 visits per calendar year) 50% 1 50% 1 Acupuncture Benefits Acupuncture by a licensed acupuncturist $25 per visit $25 per visit Acupuncture by a doctor of medicine $25 per visit 40% Rehabilitation Benefits Office location 25% 40% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visit: initial visit (for inpatient hospital services, see "Hospitalization Services) 40% Prenatal and preconception physician office visit: subsequent visits 25% 40% Postnatal physician office visits 25% 40% (for inpatient hospital services, see "Hospitalization Services) Family Planning Benefits 4, 16 Counseling and consulting Elective abortion 17 25% Tubal ligation 4 Vasectomy 17 25% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see 50% outpatient prescription drug benefits.) Diabetes self-management training (if billed by the provider, member is also responsible for an office visit copayment) $20 per visit 40% Care Outside of Plan Service Area (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental, vision, and infertility benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. 40% Up to $30 Maximum 16 Benefit Summary Guide
Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Up to $30 Maximum Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 20 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 21 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 22 35% Not covered Diabetes management referral Not covered 1 Amounts for services marked with this footnote that are paid by the member do not accrue to calendar year out-of-pocket maximum. Copayments, coinsurance and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage for additional details. 2 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of allowable amounts. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts. When members use non-participating providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield s allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. 3 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits. 4 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 5 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefits. 6 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 40% of this $350 per day, plus all charges in excess of $350. Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 17
7 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. 8 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 40% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum. 9 Services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. 10 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 11 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 12 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 13 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 14 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 15 Services from non-participating providers, home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 16 Includes insertion of IUD as well as injectable contraceptives for women. 17 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Non-participating provider facilities are not covered under this benefit. 18 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 19 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 20 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 21 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 22 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 18 Benefit Summary Guide
Preferred Full PPO for Small Business 750 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This health plan uses the Full PPO provider network. DEDUCTIBLE Participating Providers 2 Providers 2 Non-Participating Calendar Year Medical Deductible (Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year medical deductibles.) Calendar Year Brand Drug Deductible Calendar Year Out-of-Pocket Maximum 1 (Includes the medical plan deductible. Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year out-of-pocket maximums.) LIFETIME BENEFIT MAXIMUM Covered Services PROFESSIONAL SERVICES Professional (Physician) Benefits Physician office visits Specialist office visits A45904 (1/14) $750 per individual / $1,500 per family $1,500 per individual / $3,000 per family $200 per individual $6,350 per individual / $12,700 per family None $10,000 per individual / $20,000 per family Member Copayment Non-Participating Participating Providers 2 Providers 2 $20 per visit 40% $35 per visit 40% 20% 40% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging 3 (non-hospital based or affiliated) 20% 40% Outpatient diagnostic laboratory and pathology 3 20% 40% (non-hospital based or affiliated) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 20% 40% Preventive Health Benefits Preventive health services 4 (as required by applicable federal and California law) 4 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 5 20% 40% 6 Outpatient surgery in a hospital 20% 40% 6 Outpatient services for treatment of illness or injury and necessary 20% 40% 6 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $100 per visit + 20% 40% 6 procedures utilizing nuclear medicine performed in a hospital 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging performed in a hospital 3 20% 40% 6 Outpatient diagnostic laboratory and pathology performed in a 20% 40% 6 hospital 3 Bariatric surgery 7 (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only) 20% 40% 6 An Independent Member of the Blue Shield Association Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 19
HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 20% 40% Inpatient non-emergency facility services (semi-private room and board, and 20% 40% 8 medically-necessary services and supplies, including subacute care) Bariatric surgery 7 (prior authorization required; medically necessary surgery for weight 20% 40% 8 loss, for morbid obesity only) 9, 10 Skilled Nursing Facility Benefits (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 20% 20% Skilled nursing unit of a hospital 20% 40% 8 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not $100 per visit + 20% $100 per visit + 20% apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 20% 20% admitted directly from the ER) Emergency room physician services 20% 20% Urgent care $20 per visit Not covered AMBULANCE SERVICES Emergency or authorized transport (ground or air) 20% 20% 11, 12, 13 PRESCRIPTION DRUG COVERAGE Participating Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 14 Pharmacy Non-Participating Pharmacy Generic drugs $10 per prescription Preferred brand drugs $30 per prescription Non-preferred brand drugs $50 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 14 Generic drugs $20 per prescription Preferred brand drugs $60 per prescription Non-preferred brand drugs $100 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are 30% per prescription covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Preferred Providers 2 Non-Preferred Providers 2 Prosthetic equipment and devices (separate office visit copayment may apply) 20% Orthotic equipment and devices (separate office visit copayment may apply) 20% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 18 MHSA Participating Providers 2 MHSA Non-Participating Providers 2 Inpatient hospital services (prior authorization is required) 20% 40% 8 Outpatient mental health services (some services may require prior authorization and facility charges) $20 per visit 40% 20 Benefit Summary Guide
CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 18 Inpatient hospital services for medical acute detoxification (prior authorization is required) Outpatient substance abuse services (some services may require prior authorization and facility charges) Pediatric Vision Benefits Comprehensive Eye Exam 19 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) 20% 40% 8 $20 per visit HOME HEALTH SERVICES Preferred Providers 2 Non-Preferred Providers 2 Home health care agency services 9 (up to 100 prior authorized visits per 20% 15 calendar year) Home infusion/home intravenous injectable therapy and infusion 20% 15 nursing visits provided by a home infusion agency OTHER Hospice Program Benefits Routine home care 15 Inpatient respite care 15 24-hour continuous home care 15 Short-term inpatient care for pain and symptom management 15 Chiropractic Benefits 9 Chiropractic services (up to 12 visits per calendar year) 50% 1 50% 1 Acupuncture Benefits Acupuncture by a licensed acupuncturist $25 per visit $25 per visit Acupuncture by a doctor of medicine $25 per visit 40% Rehabilitation Benefits Office location 20% 40% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visit: initial visit (for inpatient hospital services, see "Hospitalization Services) 40% Prenatal and preconception physician office visit: subsequent visits 20% 40% Postnatal physician office visits 20% 40% (for inpatient hospital services, see "Hospitalization Services) Family Planning Benefits 4, 16 Counseling and consulting Elective abortion 17 20% Tubal ligation 4 Vasectomy 17 20% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see 50% outpatient prescription drug benefits.) Diabetes self-management training (if billed by the provider, member is also responsible for an office visit copayment) $20 per visit 40% Care Outside of Plan Service Area (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental, vision, and infertility benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. 40% Up to $30 Maximum Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 21
Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Up to $30 Maximum Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 20 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 21 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 22 35% Not covered Diabetes management referral Not covered 1 Amounts for services marked with this footnote that are paid by the member do not accrue to calendar year out-of-pocket maximum. Copayments, coinsurance and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage for additional details. 2 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of allowable amounts. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts. When members use non-participating providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield s allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. 3 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits. 4 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 5 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefits. 6 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 40% of this $350 per day, plus all charges in excess of $350. 22 Benefit Summary Guide
7 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. 8 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 40% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum. 9 Services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. 10 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 11 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 12 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 13 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 14 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 15 Services from non-participating providers, home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 16 Includes insertion of IUD as well as injectable contraceptives for women. 17 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Non-participating provider facilities are not covered under this benefit. 18 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 19 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 20 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 21 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 22 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 23
Enhanced Full PPO for Small Business 1250 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This health plan uses the Full provider network. DEDUCTIBLE Participating Providers 2 Providers 2 Non-Participating Calendar Year Medical Deductible (Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year medical deductibles.) Calendar Year Brand Drug Deductible Calendar Year Out-of-Pocket Maximum 1 (Includes the medical plan deductible. Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year out-of-pocket maximums.) LIFETIME BENEFIT MAXIMUM Covered Services PROFESSIONAL SERVICES Professional (Physician) Benefits Physician office visits Specialist office visits A45906 (1/14) $1,250 per individual / $2,500 per family $2,500 per individual / $5,000 per family $500 per individual $6,350 per individual/ $12,700 per family None $10,000 per individual / $20,000 per family Member Copayment Non-Participating Participating Providers 2 Providers 2 $35 per visit 50% $50 per visit 50% 30% 50% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging 3 (non-hospital based or affiliated) 30% 50% Outpatient diagnostic laboratory and pathology 3 30% 50% (non-hospital based or affiliated) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 30% 50% Preventive Health Benefits Preventive health services 4 (as required by applicable federal and California law) 4 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 5 30% 50% 6 Outpatient surgery in a hospital 30% 50% 6 Outpatient services for treatment of illness or injury and necessary 30% 50% 6 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $100 per visit + 30% 50% 6 procedures utilizing nuclear medicine performed in a hospital 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging performed in a hospital 3 30% 50% 6 Outpatient diagnostic laboratory and pathology performed in a 30% 50% 6 hospital 3 Bariatric surgery 7 (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only) 30% 50% 6 An Independent Member of the Blue Shield Association 24 Benefit Summary Guide
HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 30% 50% Inpatient non-emergency facility services (semi-private room and board, and 30% 50% 8 medically-necessary services and supplies, including subacute care) Bariatric surgery 7 (prior authorization required; medically necessary surgery for weight loss, for morbid obesity only) 30% 50% 8 9, 10 Skilled Nursing Facility Benefits (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 30% 30% Skilled nursing unit of a hospital 30% 50% 8 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not $150 per visit + 30% $150 per visit + 30% apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 30% 30% admitted directly from the ER) Emergency room physician services 30% 30% Urgent care $35 per visit Not covered AMBULANCE SERVICES Emergency or authorized transport (ground or air) 30% 30% 11, 12, 13 PRESCRIPTION DRUG COVERAGE Participating Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 14 Pharmacy Non-Participating Pharmacy Generic drugs $25 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $75 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 14 Generic drugs $50 per prescription Preferred brand drugs $100 per prescription Non-preferred brand drugs $150 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are 30% per prescription covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Participating Providers 2 Non-Participating Providers 2 Prosthetic equipment and devices (separate office visit copayment may apply) 30% Orthotic equipment and devices (separate office visit copayment may apply) 30% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 50% Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 25
MENTAL HEALTH SERVICES (PSYCHIATRIC) 18 MHSA Participating Providers 2 MHSA Non-Participating Providers 2 Inpatient hospital services (prior authorization is required) 30% 50% 8 Outpatient mental health services (some services may require prior authorization $35 per visit 50% and facility charges) CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 18 Inpatient hospital services for medical acute detoxification (prior authorization is required) Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services 9 (up to 100 prior authorized visits per calendar year) Home infusion/home intravenous injectable therapy and infusion nursing visits provided by a home infusion agency OTHER 30% 50% 8 $35 per visit Participating Providers 2 50% Non-Participating Providers 2 30% 15 30% 15 Hospice Program Benefits Routine home care 15 Inpatient respite care 15 24-hour continuous home care 15 Short-term inpatient care for pain and symptom management 15 Chiropractic Benefits Chiropractic services (up to 12 visits per calendar year) 50% 1 50% 1 Acupuncture Benefits Acupuncture by a licensed acupuncturist $25 per visit $25 per visit Acupuncture by a doctor of medicine $25 per visit 50% Rehabilitation Benefits Office location 30% 50% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visit: initial visit (for inpatient hospital services, see "Hospitalization Services 50% Prenatal and preconception physician office visit: subsequent visits 30% 50% Postnatal physician office visits 30% 50% (for inpatient hospital services, see "Hospitalization Services) Family Planning Benefits 4, 16 Counseling and consulting Elective abortion 17 30% Tubal ligation 4 Vasectomy 17 30% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see 50% outpatient prescription drug benefits.) Diabetes self-management training (if billed by the provider, member is also $35 per visit 50% responsible for an office visit copayment) Care Outside of Plan Service Area (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental, vision, and infertility benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. 26 Benefit Summary Guide
Pediatric Vision Benefits Comprehensive Eye Exam 19 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Up to $30 Maximum Up to $30 Maximum Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 20 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 21 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 22 35% Not covered Diabetes management referral Not covered 1 Amounts for services marked with this footnote that are paid by the member do not accrue to calendar year out-of-pocket maximum. Copayments, coinsurance and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage for additional details. 2 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of allowable amounts. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts. When members use non-participating providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield s allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 27
3 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits. 4 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 5 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefits. 6 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350. 7 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. 8 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 50% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum. 9 Services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. 10 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 11 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 12 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 13 This plan s prescription drug coverage provides less coverage on average than the standard benefit set by the federal government for Medicare Part D (also called noncreditable coverage). It is important to know that generally you may only enroll in a Part D plan from October 15 th through December 7 th of each year, and if you do not enroll when first eligible you may be subject to payment of higher Part D premiums when you enroll at a later date. For more information about drug coverage, call the Customer Service telephone number on your member identification card, Monday through Thursday 8:00 a.m. and 5:00 p.m. or Friday 9:00 a.m. and 5:00 p.m. 14 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 15 Services from non-participating providers, home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 16 Includes insertion of IUD as well as injectable contraceptives for women. 17 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Non-participating provider facilities are not covered under this benefit. 18 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 19 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 20 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 21 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 22 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 28 Benefit Summary Guide
Enhanced Full PPO for Small Business 2000 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This health plan uses the Full PPO provider network. DEDUCTIBLE Participating Providers 2 Providers 2 Non-Participating Calendar Year Medical Deductible (Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year medical deductibles.) Calendar Year Brand Drug Deductible Calendar Year Out-of-Pocket Maximum 1 (Includes the medical plan deductible. Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year out-of-pocket maximums.) LIFETIME BENEFIT MAXIMUM Covered Services PROFESSIONAL SERVICES Professional (Physician) Benefits Physician office visits Specialist office visits A45907 (1/14) $2,000 per individual / $4,000 per family $4,000 per individual / $8,000 per family $500 per individual $6,350 per individual/ $12,700 per family None $10,000 per individual / $20,000 per family Member Copayment Non-Participating Participating Providers 2 Providers 2 $40 per visit 50% $50 per visit 50% 30% 50% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging 3 (non-hospital based or affiliated) 30% 50% Outpatient diagnostic laboratory and pathology 3 30% 50% (non-hospital based or affiliated) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 30% 50% Preventive Health Benefits Preventive health services 4 (as required by applicable federal and California law) 4 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 5 30% 50% 6 Outpatient surgery in a hospital 30% 50% 6 Outpatient services for treatment of illness or injury and necessary 30% 50% 6 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $100 per visit + 30% 50% 6 procedures utilizing nuclear medicine performed in a hospital 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging performed in a hospital 3 30% 50% 6 Outpatient diagnostic laboratory and pathology performed in a 30% 50% 6 hospital 3 Bariatric surgery 7 (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only) 30% 50% 6 An Independent Member of the Blue Shield Association Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 29
HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 30% 50% Inpatient non-emergency facility services (semi-private room and board, and 30% 50% 8 medically-necessary services and supplies, including subacute care) Bariatric surgery 7 (prior authorization required; medically necessary surgery for weight loss, for morbid obesity only) 30% 50% 8 9, 10 Skilled Nursing Facility Benefits (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 30% 30% Skilled nursing unit of a hospital 30% 50% 8 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not $200 per visit + 30% $200 per visit + 30% apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 30% 30% admitted directly from the ER) Emergency room physician services 30% 30% Urgent care $40 per visit Not covered AMBULANCE SERVICES Emergency or authorized transport (ground or air) 30% 30% 11, 12, 13 PRESCRIPTION DRUG COVERAGE Participating Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 14 Pharmacy Non-Participating Pharmacy Generic drugs $25 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $75 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 14 Generic drugs $50 per prescription Preferred brand drugs $100 per prescription Non-preferred brand drugs $150 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are 30% per prescription covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Participating Providers 2 Non-Participating Providers 2 Prosthetic equipment and devices (separate office visit copayment may apply) 30% Orthotic equipment and devices (separate office visit copayment may apply) 30% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 18 MHSA Participating Providers 2 MHSA Non-Participating Providers 2 Inpatient hospital services (prior authorization is required) 30% 50% 8 Outpatient mental health services (some services may require prior authorization and facility charges) $40 per visit 50% 30 Benefit Summary Guide
CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 18 Inpatient hospital services for medical acute detoxification (prior authorization is required) Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services 9 (up to 100 prior authorized visits per calendar year) Home infusion/home intravenous injectable therapy and infusion nursing visits provided by a home infusion agency OTHER 30% 50% 8 $40 per visit Participating Providers 2 50% Non-Participating Providers 2 30% 15 30% 15 Hospice Program Benefits Routine home care 15 Inpatient respite care 15 24-hour continuous home care 15 Short-term inpatient care for pain and symptom management 15 Chiropractic Benefits Chiropractic services (up to 12 visits per calendar year) 50% 1 50% 1 Acupuncture Benefits Acupuncture by a licensed acupuncturist $25 per visit $25 per visit Acupuncture by a doctor of medicine $25 per visit 50% Rehabilitation Benefits Office location 30% 50% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visit: initial visit (for inpatient hospital services, see "Hospitalization Services 50% Prenatal and preconception physician office visit: subsequent visits 30% 50% Postnatal physician office visits 30% 50% (for inpatient hospital services, see "Hospitalization Services) Family Planning Benefits 4, 16 Counseling and consulting Elective abortion 17 30% Tubal ligation 4 Vasectomy 17 30% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see 50% outpatient prescription drug benefits.) Diabetes self-management training (if billed by the provider, member is also $40 per visit 50% responsible for an office visit copayment) Care Outside of Plan Service Area (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental, vision, and infertility benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 31
Pediatric Vision Benefits Comprehensive Eye Exam 19 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Up to $30 Maximum Up to $30 Maximum Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 20 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 21 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 22 30% Not covered Diabetes management referral Not covered 1 Amounts for services marked with this footnote that are paid by the member do not accrue to calendar year out-of-pocket maximum. Copayments, coinsurance and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage for additional details. 2 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of allowable amounts. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts. When members use non-participating providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield s allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. 3 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits. 32 Benefit Summary Guide
4 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 5 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefits. 6 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350. 7 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. 8 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 50% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum. 9 Services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. 10 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 11 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 12 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 13 This plan s prescription drug coverage provides less coverage on average than the standard benefit set by the federal government for Medicare Part D (also called noncreditable coverage). It is important to know that generally you may only enroll in a Part D plan from October 15 th through December 7 th of each year, and if you do not enroll when first eligible you may be subject to payment of higher Part D premiums when you enroll at a later date. For more information about drug coverage, call the Customer Service telephone number on your member identification card, Monday through Thursday 8:00 a.m. and 5:00 p.m. or Friday 9:00 a.m. and 5:00 p.m. 14 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 15 Services from non-participating providers, home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 16 Includes insertion of IUD as well as injectable contraceptives for women. 17 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Non-participating provider facilities are not covered under this benefit. 18 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 19 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 20 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 21 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 22 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 33
Basic Full PPO for Small Business 4500 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This health plan uses the Full PPO provider network. DEDUCTIBLE Participating Providers 2 Providers 2 Non-Participating Calendar Year Medical Deductible (Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year medical deductibles.) Calendar Year Brand Drug Deductible Calendar Year Out-of-Pocket Maximum 1 (Includes the medical plan deductible. Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year out-of-pocket maximums.) LIFETIME BENEFIT MAXIMUM Covered Services PROFESSIONAL SERVICES $4,500 per individual/ $9,000 per family $4,500 per individual/ $9,000 per family $500 per member $6,350 per individual/ $12,700 per family $10,000 per individual/ $20,000 per family None Member Copayment Non- Participating Participating Providers 2 Providers 2 Professional (Physician) Benefits Physician office visits $45 per visit 50% Specialist office visits $45 per visit 50% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic 40% 50% procedures utilizing nuclear medicine 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging 3 (non-hospital based or affiliated) 40% 50% Outpatient diagnostic laboratory and pathology 3 (non-hospital based or affiliated) 40% 50% Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 40% 50% Preventive Health Benefits Preventive health services 4 (as required by applicable federal and California law) A45909 (1/14) 4 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 5 40% 50% 6 Outpatient surgery in a hospital 40% 50% 6 Outpatient services for treatment of illness or injury and necessary 40% 50% 6 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $100 per visit + 40% 50% 6 procedures utilizing nuclear medicine performed in a hospital 3 (prior authorization is required) Outpatient diagnostic X-ray and imaging performed in a hospital 3 40% 50% 6 Outpatient diagnostic laboratory and pathology performed in a 40% 50% 6 hospital 3 Bariatric surgery 7 (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only) 40% 50% 6 An Independent Member of the Blue Shield Association 34 Benefit Summary Guide
HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 40% 50% Inpatient non-emergency facility services (semi-private room and board, 40% 50% 8 and medically-necessary services and supplies, including subacute care) Bariatric surgery 7 (prior authorization required; medically necessary surgery for 40% 50% 8 weight loss, for morbid obesity only) 9, 10 Skilled Nursing Facility Benefits (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 40% 40% Skilled nursing unit of a hospital 40% 50% 8 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does $200 per visit + 40% $200 per visit + 40% not apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 40% 40% admitted directly from the ER) Emergency room physician services 40% 40% Urgent care $45 per visit Not covered AMBULANCE SERVICES Emergency or authorized transport (ground or air) 40% 40% 11, 12, 13 PRESCRIPTION DRUG COVERAGE Participating Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 14 Pharmacy Non-Participating Pharmacy Generic drugs $25 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $75 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 14 Generic drugs $50 per prescription Preferred brand drugs $100 per prescription Non-preferred brand drugs $150 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs 30% per prescription are covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Preferred Providers 2 Non-Preferred Providers 2 Prosthetic equipment and devices (separate office visit copayment may 40% apply) Orthotic equipment and devices (separate office visit copayment may apply) 40% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 18 MHSA Participating Providers 2 MHSA Non-Participating Providers 2 Inpatient hospital services (prior authorization is required) 40% 50% 8 Outpatient mental health services (some services may require prior $45 per visit 50% authorization and facility charges) CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 18 Inpatient hospital services for medical acute detoxification (prior authorization is required) 40% 50% 8 Outpatient substance abuse services (some services may require prior authorization and facility charges) $45 per visit 50% Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 35
HOME HEALTH SERVICES Preferred Providers 2 Non-Preferred Providers 2 Home health care agency services 9 (up to 100 prior authorized visits per 40% 15 calendar year) Home infusion/home intravenous injectable therapy and infusion 40% 15 nursing visits provided by a home infusion agency OTHER Hospice Program Benefits Routine home care 15 Inpatient respite care 15 24-hour continuous home care 15 Short-term inpatient care for pain and symptom management 15 Chiropractic Benefits 9 Chiropractic services (up to 12 visits per calendar year) 50% 1 50% 1 medical deductible) Acupuncture Benefits Acupuncture by a licensed acupuncturist $25 per visit $25 per visit Acupuncture by a doctor of medicine $25 per visit 50% Rehabilitation Benefits Office location 40% 50% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visit: initial visit (for inpatient hospital services, see "Hospitalization Services) Prenatal and preconception physician office visit: subsequent visits Postnatal physician office visits (for inpatient hospital services, see "Hospitalization Services) Family Planning Benefits 4, 16 Counseling and consulting No Pediatric Vision Benefits Comprehensive Eye Exam 19 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) 50% 40% 50% 40% 50% Charge Elective abortion 17 40% Tubal ligation 4 Vasectomy 17 40% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see outpatient prescription drug benefits.) 50% Diabetes self-management training (if billed by the provider, member is also $45 per visit 50% responsible for an office visit copayment) Care Outside of Plan Service Area (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental, vision, and infertility benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. No charge Up to $30 Maximum Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses No charge Up to $30 Maximum 36 Benefit Summary Guide
Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. No charge Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating No charge Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 20 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 21 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 22 35% Not covered Diabetes management referral No charge Not covered 1 Amounts for services marked with this footnote that are paid by the member do not accrue to calendar year out-of-pocket maximum. Copayments, coinsurance and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage for additional details. 2 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of allowable amounts. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts. When members use non-participating providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield s allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or copayment maximum. 3 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits. 4 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 5 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefits. 6 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350. 7 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 37
8 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 50% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year outof-pocket maximum. 9 Services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. 10 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 11 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 12 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 13 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 14 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 15 Services from non-participating providers, home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 16 Includes insertion of IUD as well as injectable contraceptives for women. 17 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Non-participating provider facilities are not covered under this benefit. 18 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 19 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 20 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 21 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 22 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 38 Benefit Summary Guide
Basic Exclusive PPO for Small Business Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This plan is available only in certain California counties and cities ("Service Area") as described in the Benefit Summary Guide and the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this Plan. You must choose your doctor from this Exclusive PPO provider network. This health plan uses the Exclusive PPO provider network DEDUCTIBLE Participating Providers 1 Providers 1 Non-Participating Calendar Year Medical Deductible (Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year medical deductibles.) Calendar Year Brand Drug Deductible Calendar Year Out-of-Pocket Maximum (Includes the medical plan deductible. Copayments for covered services from participating providers accrue to both the participating and non-participating provider calendar year out-of-pocket maximums.) LIFETIME BENEFIT MAXIMUM Covered Services PROFESSIONAL SERVICES A45920 (1/14) $5,000 per individual / $10,000 per family All drugs including specialty drugs are subject to the medical deductible $6,350 per individual / $12,700 per family None $5,000 per individual / $10,000 per family $10,000 per individual / $20,000 per family Member Copayment Non-Participating Participating Providers 1 Providers 1 Professional (Physician) Benefits Physician office visits $60 per visit 50% First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, postnatal visits, urgent care visits, outpatient mental health visits and outpatient substance abuse visits. Subsequent visits are subject to the calendar year medical deductible. (first 3 visits not subject to the calendar year Specialist office visits $70 per visit 50% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine 2 (prior authorization is required) 30% 50% Outpatient diagnostic X-ray and imaging 2 (non-hospital based or affiliated) 30% 50% Outpatient diagnostic laboratory and pathology 2 30% 50% (non-hospital based or affiliated) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $60 50% Preventive Health Benefits Preventive health services 3 (as required by applicable federal and California law) 3 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 4 30% 50% 5 Outpatient surgery in a hospital 30% 50% 5 Outpatient services for treatment of illness or injury and necessary 30% 50% 5 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital 2 (prior authorization is required) 30% 50% 5 An Independent Member of the Blue Shield Association Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 39
Outpatient diagnostic X-ray and imaging performed in a hospital 2 30% 50% 5 30% 50% 5 Outpatient diagnostic laboratory and pathology performed in a hospital 2 Bariatric surgery 6 (prior authorization required; medically necessary surgery for weight 30% 50% 5 loss, for morbid obesity only) HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 30% 50% Inpatient non-emergency facility services (semi-private room and board, and 30% 50% 7 medically-necessary services and supplies, including subacute care) Bariatric surgery 6 (prior authorization required; medically necessary surgery for weight 30% 50% 7 loss, for morbid obesity only) Skilled Nursing Facility Benefits 8, 9 (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 30% 30% Skilled nursing unit of a hospital 30% 50% 7 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does not $300 per visit $300 per visit apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 30% 30% admitted directly from the ER) Emergency room physician services 30% 30% Urgent care First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, postnatal visits, urgent care visits, outpatient mental health visits and outpatient substance abuse visits. Subsequent visits are subject to the calendar year medical deductible. AMBULANCE SERVICES $120 per visit (first 3 visits not subject to the calendar year Not covered Emergency or authorized transport (ground or air) $300 $300 10, 11, 12 PRESCRIPTION DRUG COVERAGE Participating Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 13 Pharmacy Non-Participating Pharmacy Generic drugs $19 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $75 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 13 Generic drugs $38 per prescription Preferred brand drugs $100 per prescription Non-preferred brand drugs $150 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are 30% per prescription covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Preferred Providers 1 Non-Preferred Providers 1 Prosthetic equipment and devices (separate office visit copayment may apply) 30% Orthotic equipment and devices (separate office visit copayment may apply) 30% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 30% 40 Benefit Summary Guide
MENTAL HEALTH SERVICES (PSYCHIATRIC) 17 MHSA Participating Providers 1 MHSA Non-Participating Providers 1 Inpatient hospital services (prior authorization is required) 30% 50% 7 Outpatient mental health services (some services may require prior authorization $60 per visit 50% and facility charges) First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, postnatal visits, urgent care visits, outpatient mental health visits and outpatient substance abuse visits. Subsequent visits are subject to the calendar year medical deductible. (first 3 visits not subject to the calendar year CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE) 17 Inpatient hospital services for medical acute detoxification (prior authorization is required) 30% 50% 7 Outpatient substance abuse services (some services may require prior authorization and facility charges) First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, postnatal visits, urgent care visits, outpatient mental health visits and outpatient substance abuse visits. Subsequent visits are subject to the calendar year medical deductible. $60 per visit (first 3 visits not subject to the calendar year HOME HEALTH SERVICES Preferred Providers 1 Non-Preferred Providers 1 Home health care agency services 8 (up to 100 prior authorized visits per 30% 14 calendar year) Home infusion/home intravenous injectable therapy and infusion 30% 14 nursing visits provided by a home infusion agency OTHER Hospice Program Benefits Routine home care 14 Inpatient respite care 14 24-hour continuous home care 14 Short-term inpatient care for pain and symptom management 14 Chiropractic Benefits Chiropractic services Acupuncture Benefits Acupuncture by a certificated acupuncturist $60 per visit $60 per visit Acupuncture by a doctor of medicine $60 per visit 50% Rehabilitation Benefits Office location 30% 50% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (for inpatient hospital services, see "Hospitalization Services) 50% 50% Postnatal physician office visits First 3 visits per calendar year are covered prior to meeting the calendar year medical deductible combined with physician office visits, postnatal visits, urgent care visits, outpatient mental health visits and outpatient substance abuse visits. Subsequent visits are subject to the calendar year medical deductible. (for inpatient hospital services, see "Hospitalization Services) Family Planning Benefits 3, 15 Counseling and consulting No $60 per visit (first 3 visits not subject to the calendar year Charge Elective abortion 16 30% Tubal ligation 3 (Not subject to the calendar year Vasectomy 16 30% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see outpatient prescription drug benefits.) Diabetes self-management training (if billed by the provider, member is also responsible for an office visit copayment) 50% 30% $60 per visit 50% Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 41
Care Outside of Plan Service Area (benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 18 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. No charge No charge No charge Up to $30 Maximum Up to $30 Maximum Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating No charge Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 19 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 20 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 21 35% Not covered Diabetes management referral No charge Not covered 42 Benefit Summary Guide
1 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of allowable amounts. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts. When members use non-participating providers, they must pay the applicable copayment plus any amount that exceeds Blue Shield s allowable amount. Charges above the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. 2 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to your health plan's hospital services benefits. 3 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 4 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefits. 5 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-preferred hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350. 6 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. 7 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 50% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum. 8 Services with a day or visit limit accrue to the calendar year day or visit limit maximum regardless of whether the calendar year medical deductible has been met. 9 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 10 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 11 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 12 This plan s prescription drug coverage provides less coverage on average than the standard benefit set by the federal government for Medicare Part D (also called noncreditable coverage). It is important to know that generally you may only enroll in a Part D plan from October 15 th through December 7 th of each year, and if you do not enroll when first eligible you may be subject to payment of higher Part D premiums when you enroll at a later date. For more information about drug coverage, call the Customer Service telephone number on your member identification card, Monday through Thursday 8:00 a.m. and 5:00 p.m. or Friday 9:00 a.m. and 5:00 p.m. 13 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 14 Services from non-participating providers, home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 15 Includes insertion of IUD as well as injectable contraceptives for women. 16 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Non-participating provider facilities are not covered under this benefit. 17 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 18 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 19 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 20 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. 21 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. Health plans (PPO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 43
HSA-eligible high-deductible health plans (HDHPs) The HSA-HDHP plans at a glance HSA-eligible plans are high-deductible health plans that meet current health savings account (HSA) eligibility requirements. Our HSA-HDHP plans offer: Coverage for essential health benefits No charge for preventive care visits with participating providers Compatibility with an HSA, so you can enjoy potential tax savings* Choice of accessing care from either participating or non-participating providers PPO provider networks Each Blue Shield PPO plan has a provider network associated with it, consisting of participating physicians, hospitals, and other providers. You can find out which providers are in each network by going to Find a Provider at blueshieldca.com/fap. Our HSA-eligible HDHP plans use the Blue Shield of California Full PPO Provider Network. Access to care and limitations HSA-HDHP plan and member share-of-costs, like deductibles and copayments, vary based on the plan. Some services, like preventive care, are only covered when care is accessed from participating providers (providers contracted with Blue Shield). Preventive care is also covered prior to meeting the calendar-year medical deductible and with no member share-of-cost. Members who receive care from a Blue Shield PPO participating provider are responsible for meeting the applicable calendar-year medical deductible and copayment or coinsurance for the covered services, up to the calendar-year copayment maximum. Members who receive care from a non-participating provider are responsible for meeting the applicable calendar-year medical deductible and copayment or coinsurance for the covered services, as well as provider charges that exceed Blue Shield s allowable amount. Provider charges above Blue Shield s allowable amount do not accrue to the calendaryear copayment maximum. Certain healthcare services may not be available in your area. You may be required to travel in excess of 30 minutes to access these services. Please see the General Plan Information section of this guide for more information on benefit plan limitations and exclusions. * Although most consumers who enroll in an HSA-compatible health plan are eligible to open an HSA, you should consult with a financial adviser to determine if an HSA/HDHP is a good financial fit for you. Blue Shield does not offer tax advice or HSAs. HSAs are offered through financial institutions. For more information about HSAs, eligibility, and the law s current provisions, ask your financial or tax adviser. 44 Benefit Summary Guide
Enhanced Full PPO for HSA for Small Business 2000 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This health plan uses the Full PPO Provider Network. DEDUCTIBLE Participating Providers 1 Providers 1 Non-Participating Calendar Year Medical Deductible (For family coverage, the full family deductible must be met before the subscriber or covered dependents can receive benefits for covered services. Deductible accumulates separately for participating and nonparticipating providers.) Calendar Year Out-of-Pocket Maximum 1 (Includes the calendar year medical deductible. For family coverage, the full family out-of-pocket maximum must be met before the enrollee or covered dependents can receive 100% benefits for covered services. Calendar year out-of-pocket maximum accumulates separately for participating and non-participating providers.) LIFETIME BENEFIT MAXIMUM A45911 (1/14) $2,000 per individual / $4,000 per family $4,400 per individual / $8,800 per family $4,000 per individual / $8,000 per family $10,000 per individual / $20,000 per family None Covered Services Member Copayment PROFESSIONAL SERVICES Non-Participating Participating Providers 1 Providers 1 Professional (Physician) Benefits Physician office visits 20% 50% Specialist office visits 20% 50% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic 20% 50% procedures utilizing nuclear medicine 2 (prior authorization is required) Outpatient diagnostic X-ray and imaging 2 (non-hospital based or affiliated) 20% 50% Outpatient diagnostic laboratory and pathology 2 20% 50% (non-hospital based or affiliated) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 20% 50% Preventive Health Benefits Preventive health services 3 (as required by federal and California law) 3 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 4 20% 50% 5 Outpatient surgery in a hospital 20% 50% 5 Outpatient services for treatment of illness or injury and necessary 20% 50% 5 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $100 per visit + 20% 50% 5 procedures utilizing nuclear medicine performed in a hospital 2 (prior authorization is required) Outpatient diagnostic X-ray and imaging performed in a hospital 2 20% 50% 5 Outpatient diagnostic laboratory and pathology performed in a 20% 50% 5 hospital 2 Bariatric surgery 6 (prior authorization is required; medically necessary surgery for weight loss, for morbid obesity only) 20% 50% 5 An Independent Member of the Blue Shield Association Health plans (HSA) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 45
HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 20% 50% Inpatient non-emergency facility services (semi-private room and board, 20% 50% 7 and medically necessary services and supplies, including subacute care) Bariatric surgery 6 (prior authorization is required; medically necessary surgery for 20% 50% 7 weight loss, for morbid obesity only) Skilled Nursing Facility Benefits 8, 9 (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 20% 20% Skilled nursing unit of a hospital 20% 50% 7 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does $100 per visit + 20% $100 per visit + 20% not apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 20% 20% admitted directly from the ER) Emergency room physician services 20% 20% Urgent care 20% AMBULANCE SERVICES Emergency or authorized transport (ground or air) 20% 20% 10, 11, 12 PRESCRIPTION DRUG COVERAGE (subject to calendar year Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 13 Participating Pharmacy Non-Participating Pharmacy Generic drugs $25 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $75 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 13 Generic drugs $50 per prescription Preferred brand drugs $100 per prescription Non-preferred brand drugs $150 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs 30% per prescription are covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may 20% apply) Orthotic equipment and devices (separate office visit copayment may apply) 20% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 17 MHSA Participating Providers 1 MHSA Non-Participating Providers 1 Inpatient hospital services (prior authorization required) 20% 50% 7 Outpatient mental health services 20% 50% (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 17 Inpatient hospital services for medical acute detoxification 20% 50% 7 (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) 20% 50% 46 Benefit Summary Guide
HOME HEALTH SERVICES Participating Providers 1 Non-Participating Providers 1 Home health care agency services 8 (up to 100 prior authorized visits per 20% 14 calendar year) Home infusion/home intravenous injectable therapy and infusion 20% 14 nursing visits provided by a home infusion agency OTHER Hospice Program Benefits Routine home care 14 Inpatient respite care 14 24-hour continuous home care 14 Short-term inpatient care for pain and symptom management 14 Chiropractic Benefits 8 Chiropractic services Acupuncture Benefits 8 Acupuncture by a licensed acupuncturist $25 per visit $25 per visit Acupuncture by doctors of medicine $25 per visit 50% Rehabilitation Benefits Office location 20% 50% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visit: initial visit (for inpatient hospital services, see "Hospitalization Services.") Prenatal and preconception physician office visit: subsequent visits 20% 50% Postnatal physician office visits 20% 50% Family Planning Benefits 3, 15 Counseling and consulting No Charge Elective abortion 16 20% Tubal ligation 3 Vasectomy 16 20% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see Outpatient Prescription Drug Benefits. ) 50% 50% Diabetes self-management training (if billed by the provider, member is also 20% 50% responsible for an office visit copayment) Care Outside of Plan Service Area (Benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental, vision, and infertility benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 18 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses No charge No charge Up to $30 Maximum Up to $30 Maximum Health plans (HSA) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 47
Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. No charge Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating No charge Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 19 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 20 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 21 35% Not covered Diabetes management referral No charge Not covered 1 After the calendar year deductible is met, the member is responsible for a copayment or coinsurance from participating providers. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts which the member is responsible for in addition to the applicable copayment or coinsurance when accessing these providers, which amount can be substantial. Amounts applied to your calendar year deductible accrue towards the out-of-pocket maximum. Charges in excess of the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. 2 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital-based facility, or ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 3 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 4 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital, or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 5 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-participating hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350. 6 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. 7 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 50% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum. 8 Services with a day or visit limit accrue to the calendar year day or visit limit maximum, regardless of whether the calendar year medical deductible has been met. 9 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 48 Benefit Summary Guide
10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 12 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 13 Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment and are not subject to the calendar year medical deductible. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 14 Services from non-participating providers for home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 15 Includes insertion of IUD as well as injectable contraceptives for women. 16 Copayment shown is for physician services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Nonparticipating provider facilities are not covered under this benefit. 17 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 18 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 19 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 20 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 21 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. Health plans (HSA) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 49
Basic Full PPO for HSA for Small Business 3500 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This health plan uses the Full PPO Provider Network]. DEDUCTIBLE Participating Providers 1 Providers 1 Non-Participating Calendar Year Medical Deductible (For family coverage, the full family deductible must be met before the subscriber or covered dependents can receive benefits for covered services. Deductible accumulates separately for participating and nonparticipating providers.) Calendar Year Out-of-Pocket Maximum 1 (Includes the calendar year medical deductible. For family coverage, the full family out-of-pocket maximum must be met before the enrollee or covered dependents can receive 100% benefits for covered services. Calendar year out-of-pocket maximum accumulates separately for participating and non-participating providers.) LIFETIME BENEFIT MAXIMUM A45912 (1/14) $3,500 per individual / $7,000 per family $6,000 per individual / $12,000 per family $6,400 per individual / $12,800 per family $10,000 per individual / $20,000 per family None Covered Services Member Copayment PROFESSIONAL SERVICES Non-Participating Participating Providers 1 Providers 1 Professional (Physician) Benefits Physician office visits 30% 50% Specialist office visits 30% 50% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic 30% 50% procedures utilizing nuclear medicine 2 (prior authorization is required) Outpatient diagnostic X-ray and imaging 2 (non-hospital based or affiliated) 30% 50% Outpatient diagnostic laboratory and pathology 2 30% 50% (non-hospital based or affiliated) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 30% 50% Preventive Health Benefits Preventive health services 3 (as required by federal and California law) 3 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 4 30% 50% 5 Outpatient surgery in a hospital 30% 50% 5 Outpatient services for treatment of illness or injury and necessary 30% 50% 5 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $100 per visit + 30% 50% 5 procedures utilizing nuclear medicine performed in a hospital 2 (prior authorization is required) Outpatient diagnostic X-ray and imaging performed in a hospital 2 30% 50% 5 Outpatient diagnostic laboratory and pathology performed in a 30% 50% 5 hospital 2 Bariatric surgery 6 (prior authorization is required; medically necessary surgery for weight loss, for morbid obesity only) 30% 50% 5 An Independent Member of the Blue Shield Association 50 Benefit Summary Guide
HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 30% 50% Inpatient non-emergency facility services (semi-private room and board, 30% 50% 7 and medically necessary services and supplies, including subacute care) Bariatric surgery 6 (prior authorization is required; medically necessary surgery for 30% 50% 7 weight loss, for morbid obesity only) Skilled Nursing Facility Benefits 8, 9 (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 30% 30% Skilled nursing unit of a hospital 30% 50% 7 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does $100 per visit + 30% $100 per visit + 30% not apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 30% 30% admitted directly from the ER) Emergency room physician services 30% 30% Urgent care 30% AMBULANCE SERVICES Emergency or authorized transport (ground or air) 30% 30% 10, 11, 12 PRESCRIPTION DRUG COVERAGE (subject to calendar year Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 13 Participating Pharmacy Non-Participating Pharmacy Generic drugs $25 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $75 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 13 Generic drugs $50 per prescription Preferred brand drugs $100 per prescription Non-preferred brand drugs $150 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs 30% per prescription are covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may 30% apply) Orthotic equipment and devices (separate office visit copayment may apply) 30% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 17 MHSA Participating Providers 1 MHSA Non-Participating Providers 1 Inpatient hospital services (prior authorization required) 30% 50% 7 Outpatient mental health services 30% 50% (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 17 Inpatient hospital services for medical acute detoxification 30% 50% 7 (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) 30% 50% Health plans (HSA) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 51
HOME HEALTH SERVICES Participating Providers 1 Non-Participating Providers 1 Home health care agency services 8 (up to 100 prior authorized visits per 30% 14 calendar year) Home infusion/home intravenous injectable therapy and infusion 30% 14 nursing visits provided by a home infusion agency OTHER Hospice Program Benefits Routine home care 14 Inpatient respite care 14 24-hour continuous home care 14 Short-term inpatient care for pain and symptom management 14 Chiropractic Benefits 8 Chiropractic services Acupuncture Benefits 8 Acupuncture by a licensed acupuncturist $25 per visit $25 per visit Acupuncture by doctors of medicine $25 per visit 50% Rehabilitation Benefits Office location 30% 50% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visit: initial visit (for inpatient hospital services, see "Hospitalization Services.") Prenatal and preconception physician office visit: subsequent visits 30% 50% Postnatal physician office visits 30% 50% Family Planning Benefits 3, 15 Counseling and consulting No Charge Elective abortion 16 30% Tubal ligation 3 Vasectomy 16 30% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see Outpatient Prescription Drug Benefits. ) 50% 50% Diabetes self-management training (if billed by the provider, member is also 30% 50% responsible for an office visit copayment) Care Outside of Plan Service Area (Benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Comprehensive Eye Exam 18 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses No charge No charge Up to $30 Maximum Up to $30 Maximum 52 Benefit Summary Guide
Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. No charge Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating No charge Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 19 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 20 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 21 35% Not covered Diabetes management referral No charge Not covered 1 After the calendar year deductible is met, the member is responsible for a copayment or coinsurance from participating providers. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts which the member is responsible for in addition to the applicable copayment or coinsurance when accessing these providers, which amount can be substantial. Amounts applied to your calendar year deductible accrue towards the out-of-pocket maximum. Charges in excess of the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. 2 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital-based facility, or ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 3 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 4 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital, or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 5 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-participating hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350. 6 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. 7 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 50% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum. 8 Services with a day or visit limit accrue to the calendar year day or visit limit maximum, regardless of whether the calendar year medical deductible has been met. 9 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. Health plans (HSA) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 53
10 This plan s prescription drug coverage provides less coverage on average than the standard benefit set by the federal government for Medicare Part D (also called non-creditable coverage). It is important to know that generally you may only enroll in a Part D plan from October 15 th through December 7 th of each year, and if you do not enroll when first eligible you may be subject to payment of higher Part D premiums when you enroll at a later date. For more information about drug coverage, call the Customer Service telephone number on your member identification card, Monday through Thursday 8:00 a.m. and 5:00 p.m. or Friday 9:00 a.m. and 5:00 p.m. 11 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 12 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 13 Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment and are not subject to the calendar year medical deductible. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 14 Services from non-participating providers for home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 15 Includes insertion of IUD as well as injectable contraceptives for women. 16 Copayment shown is for physician services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Nonparticipating provider facilities are not covered under this benefit. 17 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 18 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 19 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 20 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 21 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 54 Benefit Summary Guide
Basic Full PPO for HSA for Small Business 5500 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND THE PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. This health plan uses the Full PPO Provider Network. DEDUCTIBLE Participating Providers 1 Providers 1 Non-Participating Calendar Year Medical Deductible (For family coverage, the full family deductible must be met before the subscriber or covered dependents can receive benefits for covered services. Deductible accumulates separately for participating and nonparticipating providers.) Calendar Year Out-of-Pocket Maximum 1 (Includes the calendar year medical deductible. For family coverage, the full family out-of-pocket maximum must be met before the enrollee or covered dependents can receive 100% benefits for covered services. Calendar year out-of-pocket maximum accumulates separately for participating and non-participating providers.) LIFETIME BENEFIT MAXIMUM A45913 (1/14) $5,500 per individual / $11,000 per family $6,350 per individual / $12,700 per family $5,500 per individual / $11,000 per family $10,000 per individual / $20,000 per family None Covered Services Member Copayment PROFESSIONAL SERVICES Non-Participating Participating Providers 1 Providers 1 Professional (Physician) Benefits Physician office visits 40% 50% Specialist office visits 40% 50% CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic 40% 50% procedures utilizing nuclear medicine 2 (prior authorization is required) Outpatient diagnostic X-ray and imaging 2 (non-hospital based or affiliated) 40% 50% Outpatient diagnostic laboratory and pathology 2 40% 50% (non-hospital based or affiliated) Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) 40% 50% Preventive Health Benefits Preventive health services 3 (as required by federal and California law) 3 OUTPATIENT SERVICES Hospital Benefits (Facility Services) Outpatient surgery performed at an ambulatory surgery center 4 40% 50% 5 Outpatient surgery in a hospital 40% 50% 5 Outpatient services for treatment of illness or injury and necessary 40% 50% 5 supplies (except as described under "Rehabilitation Benefits") CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic $100 per visit + 40% 50% 5 procedures utilizing nuclear medicine performed in a hospital 2 (prior authorization is required) Outpatient diagnostic X-ray and imaging performed in a hospital 2 40% 50% 5 Outpatient diagnostic laboratory and pathology performed in a 40% 50% 5 hospital 2 Bariatric surgery 6 (prior authorization is required; medically necessary surgery for weight loss, for morbid obesity only) 40% 50% 5 An Independent Member of the Blue Shield Association Health plans (SIMPLE Savings) Supplemental Coverage specialty Products General PLan Information Health plans (HSA) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 55
HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 40% 50% Inpatient non-emergency facility services (semi-private room and board, 40% 50% 7 and medically necessary services and supplies, including subacute care) Bariatric surgery 6 (prior authorization is required; medically necessary surgery for 40% 50% 7 weight loss, for morbid obesity only) Skilled Nursing Facility Benefits 8, 9 (combined maximum of up to 100 days per benefit period; prior authorization is required; semi-private accommodations) Services from a free-standing skilled nursing facility 40% 40% Skilled nursing unit of a hospital 40% 50% 7 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (copayment does $200 per visit + 40% $200 per visit + 40% not apply if the member is directly admitted to the hospital for inpatient services) Emergency room services resulting in admission (when the member is 40% 40% admitted directly from the ER) Emergency room physician services 40% 40% Urgent care 40% AMBULANCE SERVICES Emergency or authorized transport (ground or air) 40% 40% 10, 11, 12 PRESCRIPTION DRUG COVERAGE (subject to calendar year Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 13 Participating Pharmacy Non-Participating Pharmacy Generic drugs $25 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $75 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 13 Generic drugs $50 per prescription Preferred brand drugs $100 per prescription Non-preferred brand drugs $150 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs 40% per prescription are covered only when dispensed by Network Specialty Pharmacies. Drugs from nonparticipating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may 40% apply) Orthotic equipment and devices (separate office visit copayment may apply) 40% DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 17 MHSA Participating Providers 1 MHSA Non-Participating Providers 1 Inpatient hospital services (prior authorization required) 40% 50% 7 Outpatient mental health services 40% 50% (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 17 Inpatient hospital services for medical acute detoxification 40% 50% 7 (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) 40% 50% 56 Benefit Summary Guide
HOME HEALTH SERVICES Participating Providers 1 Non-Participating Providers 1 Home health care agency services 8 (up to 100 prior authorized visits per 40% 14 calendar year) Home infusion/home intravenous injectable therapy and infusion 40% 14 nursing visits provided by a home infusion agency OTHER Hospice Program Benefits Routine home care 14 Inpatient respite care 14 24-hour continuous home care 14 Short-term inpatient care for pain and symptom management 14 Chiropractic Benefits 8 Chiropractic services Acupuncture Benefits 8 Acupuncture by a licensed acupuncturist $25 per visit $25 per visit Acupuncture by doctors of medicine $25 per visit 50% Rehabilitation Benefits Office location 40% 50% Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visit: initial visit (for inpatient hospital services, see "Hospitalization Services.") Prenatal and preconception physician office visit: subsequent visits 40% 50% Postnatal physician office visits 40% 50% Family Planning Benefits 3, 15 Counseling and consulting No Charge Elective abortion 16 40% Tubal ligation 3 Vasectomy 16 40% Diabetes Care Benefits Devices, equipment, and non-testing supplies (for testing supplies see Outpatient Prescription Drug Benefits. ) 50% 50% Diabetes self-management training (if billed by the provider, member is also 40% 50% responsible for an office visit copayment) Care Outside of Plan Service Area (Benefits provided through the BlueCard Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider) Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Comprehensive Eye Exam 18 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses No charge No charge Up to $30 Maximum Up to $30 Maximum Health plans (HSA) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 57
Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. No charge Covered up to a maximum allowance of: $25 single vision $35 lined bifocal $45 lined trifocal $45 lenticular Optional Lenses and Treatments UV coating No charge Not covered Anti-reflective coating $35 Not covered High-index lenses $30 Not covered Photochromic lenses - plastic $25 Not covered Photochromic lenses - glass $25 Not covered Polarized lenses $45 Not covered Standard progressives $55 Not covered Premium progressives $95 Not covered Frame 19 (one frame per calendar year) Collection frames Up to $30 Maximum Contact Lenses 20 Non-Collection frames Up to $150 Maximum Up to $30 Maximum Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Up to $225 Maximum Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard hard (V2501- V2503, V2511-V2513, V2530-V2531) Up to $75 Maximum One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Up to $75 Maximum Elective (Cosmetic/Convenience) Non-standard soft (V2521- V2523) Up to $75 Maximum One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 21 35% Not covered Diabetes management referral No charge Not covered 1 After the calendar year deductible is met, the member is responsible for a copayment or coinsurance from participating providers. Participating providers accept Blue Shield s allowable amount as full payment for covered services. Non-participating providers can charge more than these amounts which the member is responsible for in addition to the applicable copayment or coinsurance when accessing these providers, which amount can be substantial. Amounts applied to your calendar year deductible accrue towards the out-of-pocket maximum. Charges in excess of the allowable amount do not count toward the calendar year deductible or out-of-pocket maximum. 2 Participating non-hospital based ("freestanding") outpatient X-ray, pathology and laboratory facilities may not be available in all areas; however the member can obtain outpatient X-ray, pathology and laboratory services from a hospital-based facility, or ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 3 Preventive Health Services, including an annual preventive care or well-baby care office visit, are not subject to the calendar year medical deductible. Other covered non-preventive services received during, or in connection with, the preventive care or well-baby care office visit are subject to the calendar year medical deductible and applicable member copayment/coinsurance. 4 Participating ambulatory surgery centers may not be available in all areas; however, the member can obtain outpatient surgery services from a hospital, or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 5 The allowable amount for non-emergency surgery and services performed in a non-participating ambulatory surgery center or outpatient unit of a non-participating hospital is $350 per day. Members are responsible for 50% of this $350 per day, plus all charges in excess of $350. 6 Bariatric surgery is covered when prior authorized by Blue Shield; however, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura Counties ("Designated Counties"), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons. Coverage is not available for bariatric services from any other participating provider and there is no coverage for bariatric services from non-participating providers. In addition, if prior authorized by Blue Shield, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Summary of Benefits and Evidence of Coverage for further details. 7 The allowable amount for non-emergency hospital services received from a non-participating hospital is $600 per day. Members are responsible for 50% of this $600 per day, plus all charges in excess of $600. Charges that exceed the allowable amount do not count toward the calendar year out-of-pocket maximum. 8 Services with a day or visit limit accrue to the calendar year day or visit limit maximum, regardless of whether the calendar year medical deductible has been met. 9 Services may require prior authorization. When services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 58 Benefit Summary Guide
10 This plan s prescription drug coverage provides less coverage on average than the standard benefit set by the federal government for Medicare Part D (also called non-creditable coverage). It is important to know that generally you may only enroll in a Part D plan from October 15 th through December 7 th of each year, and if you do not enroll when first eligible you may be subject to payment of higher Part D premiums when you enroll at a later date. For more information about drug coverage, call the Customer Service telephone number on your member identification card, Monday through Thursday 8:00 a.m. and 5:00 p.m. or Friday 9:00 a.m. and 5:00 p.m. 11 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 12 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 13 Contraceptive drugs and devices covered under the outpatient prescription drug benefit do not require a copayment and are not subject to the calendar year medical deductible. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 14 Services from non-participating providers for home health care, home infusion and hospice services are not covered unless prior authorized. When these services are prior authorized, a member s share-of-cost is paid at the participating provider amount. 15 Includes insertion of IUD as well as injectable contraceptives for women. 16 Copayment shown is for physician services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. Nonparticipating provider facilities are not covered under this benefit. 17 Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating and non-participating providers. Only Mental Health services rendered by Blue Shield MHSA participating providers are administered by the Blue Shield MHSA. Mental health services rendered by non-participating providers are administered by Blue Shield. For a listing of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield's participating providers or non-participating providers. 18 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 19 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. If frames are selected that are more expensive than the allowable amount established for this Benefit, the Member is responsible for the difference between the allowable amount and the provider s charge. 20 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 21 A report from the provider and prior authorization from the contracted VPA is required. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. Health plans (HSA) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 59
HMO health plans The HMO plans at a glance The Full HMO and Exclusive HMO for Small Business plans are our most comprehensive plans, offering a wide range of benefits including: Coverage for essential health benefits with predictable copayments No charge for preventive care office visits No charge for physician services during inpatient hospital stay (including pregnancy and maternity care) No calendar-year medical deductible No lifetime coverage maximum These plans also feature: Access+ Specialist SM for a fixed office visit copayment, members have the option of going directly to a participating Access+ Specialist in the same medical group or Independent Practice Association (IPA) as their Personal Physician without a referral. Access+ Satisfaction Our groundbreaking member feedback program gives members another option. If members are dissatisfied with the service they received during a covered office visit with an HMO network physician, they can request a refund of the standard office visit copayment. Full HMO plans The Ultimate Full HMO for Small Business $25, Preferred Full HMO for Small Business $30 and Enhanced Full HMO for Small Business $55 use the Blue Shield of California Full HMO provider network. The employer must be located and their eligible employees must live or work in the Full HMO service area. The following three Full HMO plans are offered in seven select California counties: The Ultimate Full HMO for Small Business Preferred Full HMO for Small Business Enhanced Full HMO for Small Business. These Full HMO plans use the same Blue Shield of California Full HMO provider network. The employer must be located and their eligible employees must live or work in the Full HMO service area, which includes: Alameda County Butte County Fresno County Imperial County Kings County Madera County Nevada County, except for ZIP codes 95724, 95728, 95977, 96111, 96160, 96161, and 96162. Exclusive HMO plans The Exclusive HMO plans use the Blue Shield of California Exclusive Provider Network and offer you a way to manage your bottom-line costs, while giving your employees access to comprehensive quality healthcare coverage. These Exclusive HMO plans offer all the great benefits of our comprehensive Full HMO plans and feature a select network of quality physicians. The Exclusive HMO plans are available in certain California counties and cities (the service area ). The employer must be located and their eligible employees must live or work in the Exclusive HMO service area, which includes the following six Southern California, nine Northern California, and three Central California counties: Southern California Los Angeles County, except for ZIP codes 90704, 93510, 93532, 93534, 93535, 93536, 93539, 93543, 93544, 93550, 93551, 93552, 93553, 93584, 93586, 93590, 93591, and 93599 Orange County Riverside County, except for ZIP codes 92225, 92226, 92239, 92275, and 92539 San Bernardino County, except for ZIP codes 91759, 92252, 92256, 92267, 92268, 92277, 92278, 92284, 92285, 92286, 92304, 92305, 92309, 92310, 92314, 92315, 92317, 92321, 92322, 92323, 92325, 92326, 92327, 92332, 92333, 92338, 92341, 92342, 92347, 92352, 92356, 92358, 92364, 92365, 92366, 92368, 92372, 92378, 92382, 92385, 92386, 92391, 92395, 92397, 92398, 92407, 93523, 93562, and 93592 San Diego County, except for ZIP codes 91905, 91906, 91934, 91963, 91980, 91987, 92004, 92036, 92066, and 92086 Ventura County, except for ZIP codes 91307, 91358, 91359, 91360, 91361, 91362, 91377, 93020, 93021, 93040, 93042, 93062, 93063, 93064, 93065, 93094, and 93099 60 Benefit Summary Guide
Northern California Contra Costa County, except for ZIP codes 94525, 94530, 94547, 94564, 94569, 94572, 94801, 94802, 94803, 94804, 94805, 94806, 94807, 94808, 94820, and 94850 Marin County Sacramento County, except for ZIP codes 95632, 95638, 95639, 95641, 95671, 95680, 95683, 95690, 95693, 95798, and 95799 San Francisco County Santa Clara County Santa Cruz County San Mateo County, except for ZIP codes 94018, 94019, 94020, 94021, 94028, 94037, 94038, 94060, and 94074 Sonoma County Yolo County Central California Kern County, except for ZIP codes 93205, 93206, 93220, 93222, 93224, 93225, 93226, 93238, 93240, 93243, 93249, 93251, 93252, 93255, 93555, 93558, 93268, 93283, 93285, 93287, 93501, 93502, 93504, 93505, 93516, 93518, 93519, 93524, 93560, and 93596 San Luis Obispo County Stanislaus County Out-of-area considerations Full HMO plans and Exclusive HMO plans are designed to provide coverage for employees who live or work in that plan s service area. Because only emergency and urgent care coverage is available outside of the HMO plan service area, employers with employees who reside or work for more than six months outside the plan s service area should consider a PPO plan. This does not apply to students, long-term travelers, and workers on extended out-of-state assignments enrolled in the Away From Home Care program. The Blue Shield of California Full HMO plan and Exclusive HMO plan service areas are identified in the HMO Physician and Hospital Directory. The Local Full HMO plans are available only in certain California counties and cities ( service area ) as described on page 60. In addition, each employee and eligible family member must designate a Personal Physician to enroll and maintain enrollment in the HMO plan. The employee and family members may select different Personal Physicians, as long as each provider is located adequately close to the individual s home or work address to ensure access to care as determined by Blue Shield of California. Access to care and limitations Full HMO and Exclusive HMO plan members must contact their Personal Physician to provide, arrange, or coordinate all covered services (except emergencies, OB/GYN care, mental health, and substance abuse*), including: Preventive care services routine health problems referral for consultation with specialists (excludes Access+ Specialist) Urgent care services within the member s Personal Physician service area Hospitalization * Members must pay in full for all services not authorized by their Personal Physician, except when using the Access+ Specialist option, OB/GYN services, emergency and urgent care services. Except for emergencies, members must contact the mental health service administrator (MHSA) for mental health and substance abuse services to be covered. Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 61
Limitations on Access+ Specialist visits 1. To access the Access+ Specialist benefit, you must choose a Personal Physician in a medical group or IPA that participates in the Access+ program. The Access+ designation will appear on your Blue Shield member ID card with a + after the name of your IPA/medical group. The Access+ Specialist option applies to basic examinations and consultations provided by a physician (an M.D. or D.O.) in his or her office. The Access+ Specialist option does not apply to: Any services that are not medically necessary or not a covered benefit Services that are not considered to be a physician office visit, such as outpatient or inpatient surgery Services provided by non-physicians, such as podiatrists or physical therapists Emergency or urgent care services Services that members may obtain without a referral required from their Personal Physician s medical group or IPA (for example, female members may visit an OB/GYN or family practice physician in the same medical group or IPA as their Personal Physician for OB/GYN services without a referral) Psychological testing and evaluation 2. During an Access+ Specialist visit, a physician may order certain X-rays and laboratory services without prior authorization. However, the following services still require prior authorization from a member s Personal Physician s medical group or IPA: Allergy testing Endoscopic procedures Diagnostic imaging, including CT, MRI, or bonedensity measurement Chemotherapy or other infusion drugs and injectables other than vaccines and antibiotics All infertility services 3. For mental health and chemical dependency Access+ Specialist visits, members must use MHSA participating providers. Certain healthcare services may not be available in your area. You may be required to travel in excess of 30 minutes to access these services. Please see the General Plan Information section of this guide for more information on plan limitations and exclusions. The Exclusive network includes a subset of physicians, IPAs and Medical groups from our Full Network. 62 Benefit Summary Guide
Ultimate Full HMO for Small Business $25 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This health plan uses the Full HMO provider network DEDUCTIBLE Calendar Year Facility Deductible None Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $2,500 per individual / $5,000 per family Calendar Year Brand Drug Deductible None LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $25 per visit (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 diagnostic X-ray and imaging Outpatient diagnostic pathology and laboratory Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $25 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $50 per visit 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 $100 per surgery Outpatient surgery in a hospital $150 per surgery Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medicallynecessary services and supplies, including subacute care) $250 per day up to 3 days per admission Inpatient medically necessary skilled nursing services including subacute care 4 $100 per day EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (a copayment does not apply if the $200 per visit member is directly admitted to the hospital for inpatient services) Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport (ground or air) $100 A45915(1/14) An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 63
5, 9, 10 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) $5 per prescription $15 per prescription $25 per prescription $10 per prescription $30 per prescription $50 per prescription 20% per prescription DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) $250 per day up to 3 days per admission Outpatient mental health services $25 per visit (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 visits per calendar year) Medical supplies (see "prescription drug coverage" for specialty drugs) $250 per day up to 3 days per admission $25 per visit $25 per visit OTHER Hospice Program Benefits Routine home care Inpatient respite care 24-hour continuous home care Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) $15 per visit 1 Acupuncture Benefits Acupuncture visits Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (for inpatient hospital services, see "hospitalization services") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation Elective abortion 8 Vasectomy 8 $15 per visit $25 per visit 50% 1 $100 per surgery $75 per surgery 64 Benefit Summary Guide
Rehabilitation Benefits Office location (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; for testing supplies see outpatient prescription drug benefits) $25 per visit Diabetes self-management training $25 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $25 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Anti-reflective coating $35 High-index lenses $30 Photochromic lenses - plastic $25 Photochromic lenses - glass $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Up to $150 Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530- V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 35% Diabetes management referral 50% Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 65
1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses.. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 66 Benefit Summary Guide
Ultimate Exclusive HMO for Small Business $25 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This plan is available only in certain California counties and cities ("Service Area") as described in the Benefit Summary Guide and the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this Plan. You must choose your doctor from this Exclusive HMO provider network. This health plan uses the Exclusive HMO provider network DEDUCTIBLE Calendar Year Facility Deductible None Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $2,500 per individual / $5,000 per family Calendar Year Brand Drug Deductible None LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $25 per visit (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 diagnostic X-ray and imaging Outpatient diagnostic pathology and laboratory Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $25 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $50 per visit 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 $100 per surgery Outpatient surgery in a hospital $150 per surgery Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medicallynecessary services and supplies, including subacute care) $250 per day up to 3 days per admission Inpatient medically necessary skilled nursing services including subacute care 4 $100 per day EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (a copayment does not apply if the $200 per visit member is directly admitted to the hospital for inpatient services) Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport (ground or air) $100 A45914 (1/14) An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 67
5, 9, 10 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) $5 per prescription $15 per prescription $25 per prescription $10 per prescription $30 per prescription $50 per prescription 20% per prescription DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) $250 per day up to 3 days per admission Outpatient mental health services $25 per visit (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 visits per calendar year) Medical supplies (see "prescription drug coverage" for specialty drugs) $250 per day up to 3 days per admission $25 per visit $25 per visit OTHER Hospice Program Benefits Routine home care Inpatient respite care 24-hour continuous home care Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) $15 per visit 1 Acupuncture Benefits Acupuncture visits $15 per visit Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (for inpatient hospital services, see "hospitalization services") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation Elective abortion 8 $25 per visit 50% 1 $100 per surgery 68 Benefit Summary Guide
Vasectomy 8 Rehabilitation Benefits Office location (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; for testing supplies see outpatient prescription drug benefits) $75 per surgery $25 per visit Diabetes self-management training $25 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $25 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Anti-reflective coating $35 High-index lenses $30 Photochromic lenses - plastic $25 Photochromic lenses - glass $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Up to $150 Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530- V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 35% Diabetes management referral 50% Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 69
1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 70 Benefit Summary Guide
Ultimate Full HMO for Small Business Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This plan is available only in certain California counties and cities ("Service Area") as described in the Benefit Summary Guide and the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this Plan.You must choose your doctor from this Full HMO provider network. This health plan uses the Full HMO provider network DEDUCTIBLE Calendar Year Medical Deductible None Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $4,000 per individual / $8,000 per family Calendar Year Brand Drug Deductible None LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $20 per visit (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 diagnostic X-ray and imaging $40 per visit Outpatient diagnostic pathology and laboratory $20 per visit Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $20 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $40 per visit 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 $250 per surgery Outpatient surgery in a hospital $250 per surgery Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and $250 per day up to 5 days per admission medically-necessary services and supplies, including subacute care) Inpatient medically necessary skilled nursing services including subacute care 4 $150 per day up to 5 days per admission EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (a copayment does not apply if the $150 per visit member is directly admitted to the hospital for inpatient services) Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport (ground or air) $150 A45922 (1/14) An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 71
5, 9, 10, 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) $5 per prescription $15 per prescription $25 per prescription $10 per prescription $30 per prescription $50 per prescription 10% per prescription DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 10% MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) Outpatient mental health services (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) 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 Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) Acupuncture Benefits Acupuncture visits Pregnancy and Maternity Care Benefits Prenatal and preconceptionl physician office visits (for inpatient hospital services, see "hospitalization services") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (Member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation Elective abortion 8 Vasectomy 8 Rehabilitation Benefits Office location (copayment applies to all places of services, including professional and facility settings) $250 per day up to 5 days per admission $20 per visit $250 per day up to 5 days per admission $20 per visit $20 per visit $20 per visit $20 per visit 50% 1 $250 per surgery $250 per surgery $20 per visit 72 Benefit Summary Guide
Diabetes Care Benefits Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for testing supplies see outpatient prescription drug benefits) Diabetes self-management training $20 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $40 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Anti-reflective coating $35 High-index lenses $30 Photochromic lenses - plastic $25 Photochromic lenses - glass $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Up to $150 Maximum Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530- V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 35% Diabetes management referral 10% Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 73
1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 74 Benefit Summary Guide
Ultimate Exclusive HMO for Small Business Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This plan is available only in certain California counties and cities ("Service Area") as described in the Benefit Summary Guide and the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this Plan. You must choose your doctor from this Exclusive HMO provider network. This health plan uses the Exclusive HMO provider network DEDUCTIBLE Calendar Year Medical Deductible None Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $4,000 per individual / $8,000 per family Calendar Year Brand Drug Deductible None LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $20 per visit (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 diagnostic X-ray and imaging $40 per visit Outpatient diagnostic pathology and laboratory $20 per visit Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $20 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $40 per visit 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 $250 per surgery Outpatient surgery in a hospital $250 per surgery Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and $250 per day up to 5 days per admission medically-necessary services and supplies, including subacute care) Inpatient medically necessary skilled nursing services including subacute care 4 $150 per day up to 5 days per admission EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (a copayment does not apply if the $150 per visit member is directly admitted to the hospital for inpatient services) Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport (ground or air) $150 A45921 (1/14) An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 75
5, 9, 10, 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) $5 per prescription $15 per prescription $25 per prescription $10 per prescription $30 per prescription $50 per prescription 10% per prescription DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 10% MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) $250 per day up to 5 days per admission Outpatient mental health services $20 per visit (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) 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 Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) Acupuncture Benefits Acupuncture visits Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (for inpatient hospital services, see "hospitalization services") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (Member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation Elective abortion 8 Vasectomy 8 Rehabilitation Benefits Office location (copayment applies to all places of services, including professional and facility settings) $250 per day up to 5 days per admission $20 per visit $20 per visit $20 per visit $20 per visit 50% 1 $250 per surgery $250 per surgery $20 per visit 76 Benefit Summary Guide
Diabetes Care Benefits Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for testing supplies see outpatient prescription drug benefits) Diabetes self-management training $20 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $40 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Anti-reflective coating $35 High-index lenses $30 Photochromic lenses - plastic $25 Photochromic lenses - glass $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Up to $150 Maximum Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530- V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 35% Diabetes management referral 10% Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 77
1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 78 Benefit Summary Guide
Preferred Full HMO for Small Business $30 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This health plan uses the Full HMO provider network DEDUCTIBLE Calendar Year Facility Deductible $2,000 Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $5,000 per individual / $10,000 per family Calendar Year Brand Drug Deductible $350 LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $30 per visit (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 diagnostic X-ray and imaging Outpatient diagnostic pathology and laboratory Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $30 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $50 per visit 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 $150 per surgery Outpatient surgery in a hospital $300 per surgery Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medicallynecessary services and supplies, including subacute care) 20% Inpatient medically necessary skilled nursing services including subacute care 4 $150 per day EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (a copayment does not apply if the $200 per visit member is directly admitted to the hospital for inpatient services) Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport (ground or air) $100 A45917 (1/14)] An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 79
5, 9, 10, 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) $15 per prescription $30 per prescription $50 per prescription $30 per prescription $60 per prescription $100 per prescription 20% per prescription DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) 20% Outpatient mental health services $30 per visit (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 visits per calendar year) Medical supplies (see "prescription drug coverage" for specialty drugs) 20% $30 per visit $30 per visit OTHER Hospice Program Benefits Routine home care Inpatient respite care 24-hour continuous home care Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) $15 per visit 1 Acupuncture Benefits Acupuncture visits $15 per visit Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (For inpatient hospital services, see "hospitalization services.") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation Elective abortion 8 Vasectomy 8 $30 per visit 50% 1 $100 per surgery $75 per surgery 80 Benefit Summary Guide
Rehabilitation Benefits Office location (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; for testing supplies see outpatient prescription drug benefits.) $30 per visit Diabetes self-management training $30 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $30 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Tint (solid and gradient) 50% Anti-reflective coating $35 High-index lenses $30 Photochromic lenses (plastic only) Polarized lenses $45 Standard progressives $55 Premium progressives $95 Blended segment lenses $20 Intermediate vision lenses $30 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530-V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Up to $150 Maximum Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 81
Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 35% Diabetes management referral 1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 82 Benefit Summary Guide
Preferred Exclusive HMO for Small Business $30 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This plan is available only in certain California counties and cities ("Service Area") as described in the Benefit Summary Guide and the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this Plan. You must choose your doctor from this Exclusive HMO provider network. This health plan uses the Exclusive HMO provider network DEDUCTIBLE Calendar Year Facility Deductible $2,000 Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $5,000 per individual / $10,000 per family Calendar Year Brand Drug Deductible $350 LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $30 per visit (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 diagnostic X-ray and imaging Outpatient diagnostic pathology and laboratory Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $30 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $50 per visit 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 $150 per surgery Outpatient surgery in a hospital $300 per surgery Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medicallynecessary services and supplies, including subacute care) 20% Inpatient medically necessary skilled nursing services including subacute care 4 $150 per day EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (a copayment does not apply if the $200 per visit member is directly admitted to the hospital for inpatient services) Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport (ground or air) $100 A45916 (1/14) An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 83
5, 9, 10, 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) $15 per prescription $30 per prescription $50 per prescription $30 per prescription $60 per prescription $100 per prescription 20% per prescription DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 50% MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) 20% Outpatient mental health services $30 per visit (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 visits per calendar year) Medical supplies (see "prescription drug coverage" for specialty drugs) 20% $30 per visit $30 per visit OTHER Hospice Program Benefits Routine home care Inpatient respite care 24-hour continuous home care Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) $15 per visit 1 Acupuncture Benefits Acupuncture visits $15 per visit Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (For inpatient hospital services, see "hospitalization services.") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation Elective abortion 8 Vasectomy 8 $30 per visit 50% 1 $100 per surgery $75 per surgery 84 Benefit Summary Guide
Rehabilitation Benefits Office location (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; for testing supplies see outpatient prescription drug benefits.) $30 per visit Diabetes self-management training $30 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $30 per visit Optional Benefits Optional dental and visionbenefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Tint (solid and gradient) 50% Anti-reflective coating $35 High-index lenses $30 Photochromic lenses (plastic only) Polarized lenses $45 Standard progressives $55 Premium progressives $95 Blended segment lenses $20 Intermediate vision lenses $30 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530-V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Up to $150 Maximum Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 85
Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 35% Diabetes management referral 1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 86 Benefit Summary Guide
Preferred Full HMO for Small Business Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This plan is available only in certain California counties and cities ("Service Area") as described in the Benefit Summary Guide and the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this Plan.You must choose your doctor from this Full HMO provider network. This health plan uses the Full HMO provider network DEDUCTIBLE Calendar Year Medical Deductible None Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $6,350 per individual / $12,700 per family Calendar Year Brand Drug Deductible None LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $30 per visit (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 diagnostic X-ray and imaging $50 per visit Outpatient diagnostic pathology and laboratory $30 per visit Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $30 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $50 per visit 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 $600 per surgery Outpatient surgery in a hospital $600 per surgery Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medically-necessary services and supplies, including subacute care) Inpatient medically necessary skilled nursing services including subacute care 4 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (a copayment does not apply if the member is directly admitted to the hospital for inpatient services) Emergency room physician services A45924 (1/14) $600 per day up to 5 days per admission $300 per day up to 5 days per admission $250 per visit An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 87
AMBULANCE SERVICES Emergency or authorized transport (ground or air) $250 5, 9, 10, 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs $19 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $70 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs $38 per prescription Preferred brand drugs $100 per prescription Non-preferred brand drugs $140 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when 20% per prescription dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 20% MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) Outpatient mental health services (some services may require prior authorization and facility CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility 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 Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) Acupuncture Benefits Acupuncture visits Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (for inpatient hospital services, see "hospitalization services") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) $600 per day up to 5 days per admission $30 per visit $600 per day up to 5 days per admission $30 per visit $30 per visit $30 per visit $30 per visit 50% 1 88 Benefit Summary Guide
Tubal ligation Elective abortion 8 Vasectomy 8 Rehabilitation Benefits Office location (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; for testing supplies see outpatient prescription drug benefits) Diabetes self-management training Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $600 per surgery $600 per surgery $30 per visit 20% $30 per visit $60 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Anti-reflective coating $35 High-index lenses $30 Photochromic lenses - plastic $25 Photochromic lenses - glass $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Up to $150 Maximum Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530- V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 89
Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 35% Diabetes management referral 1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 90 Benefit Summary Guide
Preferred Exclusive HMO for Small Business Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This plan is available only in certain California counties and cities ("Service Area") as described in the Benefit Summary Guide and the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this Plan. You must choose your doctor from this Exclusive HMO provider network. This health plan uses the Exclusive HMO provider network DEDUCTIBLE Calendar Year Medical Deductible None Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $6,350 per individual / $12,700 per family Calendar Year Brand Drug Deductible None LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $30 per visit (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 diagnostic X-ray and imaging $50 per visit Outpatient diagnostic pathology and laboratory $30 per visit Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $30 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $50 per visit 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 $600 per surgery Outpatient surgery in a hospital $600 per surgery Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medically-necessary services and supplies, including subacute care) Inpatient medically necessary skilled nursing services including subacute care 4 EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (a copayment does not apply if the member is directly admitted to the hospital for inpatient services) Emergency room physician services A45923 (1/14) $600 per day up to 5 days per admission $300 per day up to 5 days per admission $250 per visit An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 91
AMBULANCE SERVICES Emergency or authorized transport (ground or air) $250 5, 9, 10, 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs $19 per prescription Preferred brand drugs $50 per prescription Non-preferred brand drugs $70 per prescription Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs $38 per prescription Preferred brand drugs $100 per prescription Non-preferred brand drugs $140 per prescription Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when 20% per prescription dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 20% MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) $600 per day up to 5 days per admission Outpatient mental health services $30 per visit (some services may require prior authorization and facility CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility 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 Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) Acupuncture Benefits Acupuncture visits Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (for inpatient hospital services, see "hospitalization services") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) $600 per day up to 5 days per admission $30 per visit $30 per visit $30 per visit $30 per visit 50% 1 92 Benefit Summary Guide
Tubal ligation Elective abortion 8 Vasectomy 8 Rehabilitation Benefits Office location (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; for testing supplies see outpatient prescription drug benefits) $600 per surgery $600 per surgery $30 per visit Diabetes self-management training $30 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $60 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Anti-reflective coating $35 High-index lenses $30 Photochromic lenses - plastic $25 Photochromic lenses - glass $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Up to $150 Maximum Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530- V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year 20% Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 93
Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 35% Diabetes management referral 1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 94 Benefit Summary Guide
Enhanced Full HMO for Small Business $55 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This health plan uses the Full HMO provider network DEDUCTIBLE Calendar Year Facility Deductible $2,000 per indidvidual Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $6,350 per individual / $12,700 per family Calendar Year Brand Drug Deductible $500 per individual LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $55 per visit (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 diagnostic X-ray and imaging $15 Outpatient diagnostic pathology and laboratory $10 Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $55 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $55 per visit 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 40% Outpatient surgery in a hospital 40% Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medicallynecessary services and supplies, including subacute care) 40% Inpatient medically necessary skilled nursing services including subacute care 4 40% EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (a copayment does not apply if the $200 per visit member is directly admitted to the hospital for inpatient services) Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport (ground or air) $100 A45919 (1/14) An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 95
5, 9, 10, 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) $25 per prescription $55 per prescription $75 per prescription $50 per prescription $110 per prescription $150 per prescription 20% per prescription DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 50 % MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) 40% Outpatient mental health services $55 per visit (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 visits per calendar year) Medical supplies (see "prescription drug coverage" for specialty drugs) 40% $55 per visit $55 per visit OTHER Hospice Program Benefits Routine home care Inpatient respite care 24-hour continuous home care Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) $15 per visit 1 Acupuncture Benefits Acupuncture visits $15 per visit Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (For inpatient hospital services, see "hospitalization services.") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation Elective abortion 8 Vasectomy 8 $55 per visit 50% 1 $100 per surgery $75 per surgery 96 Benefit Summary Guide
Rehabilitation Benefits Office location (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; for testing supplies see outpatient prescription drug benefits) $55 per visit Diabetes self-management training $55 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $55 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Tint (solid and gradient) Anti-reflective coating $35 High-index lenses $30 Photochromic lenses (plastic only) Polarized lenses $45 Standard progressives $55 Premium progressives $95 Blended segment lenses $20 Intermediate vision lenses $30 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Up to $150 Maximum Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530- V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 40% Diabetes management referral 50% Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 97
\ 1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 98 Benefit Summary Guide
Enhanced Exclusive HMO for Small Business $55 Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This plan is available only in certain California counties and cities ("Service Area") as described in the Benefit Summary Guide and the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this Plan. You must choose your doctor from this Exclusive HMO provider network. This health plan uses the Exclusive HMO provider network DEDUCTIBLE Calendar Year Facility Deductible $2,000 per individual Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $6,350 per individual / $12,700 per family Calendar Year Brand Drug Deductible $500 per individual LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $55 per visit (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 diagnostic X-ray and imaging $15 Outpatient diagnostic pathology and laboratory $10 Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $55 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $55 per visit 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 40% Outpatient surgery in a hospital 40% Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services Inpatient non-emergency facility services (semi-private room and board, and medicallynecessary services and supplies, including subacute care) 40% Inpatient medically necessary skilled nursing services including subacute care 4 40% EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (a copayment does not apply if the $200 per visit member is directly admitted to the hospital for inpatient services) Emergency room physician services AMBULANCE SERVICES Emergency or authorized transport (ground or air) $100 A45918 (1/14) An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 99
5, 9, 10, 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) $25 per prescription $55 per prescription $75 per prescription $50 per prescription $110 per prescription $150 per prescription 20% per prescription DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 50 % MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) 40% Outpatient mental health services $55 per visit (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) HOME HEALTH SERVICES Home health care agency services (up to 100 visits per calendar year) Medical supplies (see "prescription drug coverage" for specialty drugs) 40% $55 per visit $55 per visit OTHER Hospice Program Benefits Routine home care Inpatient respite care 24-hour continuous home care Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) $15 per visit 1 Acupuncture Benefits Acupuncture visits $15 per visit Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (For inpatient hospital services, see "hospitalization services.") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation Elective abortion 8 Vasectomy 8 $55 per visit 50% 1 $100 per surgery $75 per surgery 100 Benefit Summary Guide
Rehabilitation Benefits Office location (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; for testing supplies see outpatient prescription drug benefits) $55 per visit Diabetes self-management training $55 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $55 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Tint (solid and gradient) Anti-reflective coating $35 High-index lenses $30 Photochromic lenses (plastic only) Polarized lenses $45 Standard progressives $55 Premium progressives $95 Blended segment lenses $20 Intermediate vision lenses $30 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Up to $150 Maximum Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530- V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 40% Diabetes management referral 50% Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 101
1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 102 Benefit Summary Guide
Enhanced Full HMO for Small Business Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This plan is available only in certain California counties and cities ("Service Area") as described in the Benefit Summary Guide and the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this Plan. You must choose your doctor from this Full HMO provider network. This health plan uses the Full HMO provider network DEDUCTIBLE Calendar Year Medical Deductible $1,500 Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $6,350 per individual / $12,700 per family Calendar Year Brand Drug Deductible $500 per individual / $1,000 per family LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $45 per visit (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 diagnostic X-ray and imaging $65 per visit Outpatient diagnostic pathology and laboratory $45 per visit Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $45 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $65 per visit 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 20% Outpatient surgery in a hospital 20% Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 20% (subject to the calendar year medical deductible) Inpatient non-emergency facility services (semi-private room and board, and medically-necessary services and supplies, including subacute care) A45926 (1/14) 20% (subject to the calendar year medical deductible) Inpatient medically necessary skilled nursing services including subacute care 4 20% (subject to the calendar year medical deductible) Health plans (HMO) Supplemental Coverage specialty Products General PLan Information An Independent Member of the Blue Shield Association Benefit Summary Guide 103
EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (A copayment does not apply if the member is directly admitted to the hospital for inpatient services) Emergency room physician services $250 per visit (subject to the calendar year medical deductible) AMBULANCE SERVICES Emergency or authorized transport (ground or air) $250 (subject to the calendar year medical deductible) 5, 9, 10, 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) DURABLE MEDICAL EQUIPMENT Breast pump $19 per prescription $50 per prescription $70 per prescription $38 per prescription $100 per prescription $140 per prescription 20% per prescription Other durable medical equipment (member share is based upon allowed charges) 20% MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) 20% (subject to the calendar year medical deductible) Outpatient mental health services $45 per visit (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) 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 Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) Acupuncture Benefits Acupuncture visits 20% (subject to the calendar year medical deductible) $45 per visit $45 per visit $45 per visit 104 Benefit Summary Guide
Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (for inpatient hospital services, see "hospitalization services") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) $45 per visit 50% 1 Tubal ligation Elective abortion 8 20% Vasectomy 8 20% Rehabilitation Benefits Office location (copayment applies to all places of services, including professional and facility settings) $45 per visit Diabetes Care Benefits Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for testing 20% supplies see outpatient prescription drug benefits) Diabetes self-management training $45 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $90 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Anti-reflective coating $35 High-index lenses $30 Photochromic lenses - plastic $25 Photochromic lenses - glass $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Up to $150 Maximum Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 105
Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530- V2531) One pair per Calendar Year Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 35% Diabetes management referral 1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 106 Benefit Summary Guide
Enhanced Exclusive HMO for Small Business Benefit Summary (For groups 1 to 50) (Uniform Health Plan Benefits and Coverage Matrix) Blue Shield of California Effective January 1, 2014 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. This plan is available only in certain California counties and cities ("Service Area") as described in the Benefit Summary Guide and the Evidence of Coverage. You must live and/or work in this select Service Area in order to enroll in this Plan.You must choose your doctor from this Exclusive HMO provider network. This health plan uses the Exclusive HMO provider network DEDUCTIBLE Calendar Year Medical Deductible $1,500 Calendar Year Out-of-Pocket Maximum 1 (For many covered services) $6,350 per individual / $12,700 per family Calendar Year Brand Drug Deductible $500 per individual / $1,000 per family LIFETIME BENEFIT MAXIMUM None Covered Services Member Copayment PROFESSIONAL SERVICES Professional (Physician) Benefits Physician and specialist office visits $45 per visit (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 diagnostic X-ray and imaging $65 per visit Outpatient diagnostic pathology and laboratory $45 per visit Allergy Testing and Treatment Benefits Office visits (includes visits for allergy serum injections) $45 per visit Access+ Specialist SM Benefits 2 Office visit, examination or other consultation (self-referred office visits and consultations only) $65 per visit 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 20% Outpatient surgery in a hospital 20% Outpatient services for treatment of illness or injury and necessary supplies (except as described under "Rehabilitation Benefits") HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) Inpatient physician services 20% (subject to the calendar year Inpatient non-emergency facility services (semi-private room and board, and medically-necessary services and supplies, including subacute care) A45925(1/14) 20% (subject to the calendar year Inpatient medically necessary skilled nursing services including subacute care 4 20% (subject to the calendar year EMERGENCY HEALTH COVERAGE Emergency room services not resulting in admission (A copayment does not apply if the member is directly admitted to the hospital for inpatient services) Emergency room physician services $250 per visit (subject to the calendar year An Independent Member of the Blue Shield Association Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 107
AMBULANCE SERVICES Emergency or authorized transport (ground or air) $250 (subject to the calendar year 5, 9, 10, 11 PRESCRIPTION DRUG COVERAGE Retail Prescriptions (up to a 30-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Mail Service Prescriptions (up to a 90-day supply) Contraceptive drugs and devices 6 Generic drugs Preferred brand drugs Non-preferred brand drugs Specialty Pharmacies (up to a 30-day supply) Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except in emergency and urgent situations.) PROSTHETICS/ORTHOTICS Prosthetic equipment and devices (separate office visit copayment may apply) Orthotic equipment and devices (separate office visit copayment may apply) $19 per prescription $50 per prescription $70 per prescription $38 per prescription $100 per prescription $140 per prescription 20% per prescription DURABLE MEDICAL EQUIPMENT Breast pump Other durable medical equipment (member share is based upon allowed charges) 20% MENTAL HEALTH SERVICES (PSYCHIATRIC) 16 Inpatient hospital services (prior authorization required) 20% (subject to the calendar year medical deductible) Outpatient mental health services (some services may require prior authorization and facility charges) CHEMICAL DEPENDENCY SERVICES 16 Inpatient hospital services for medical acute detoxification (prior authorization required) Outpatient substance abuse services (some services may require prior authorization and facility charges) 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 Short-term inpatient care for pain and symptom management Chiropractic Benefits Chiropractic services (up to 15 visits per calendar year) Acupuncture Benefits Acupuncture visits Pregnancy and Maternity Care Benefits Prenatal and preconception physician office visits (for inpatient hospital services, see "hospitalization services") Postnatal Physician office visits Family Planning and Infertility Benefits Counseling and consulting 7 $45 per visit 20% (subject to the calendar year medical deductible) $45 per visit $45 per visit $45 per visit $45 per visit 108 Benefit Summary Guide
Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT) Tubal ligation Elective abortion 8 20% Vasectomy 8 20% Rehabilitation Benefits Office location (copayment applies to all places of services, including professional and facility settings) $45 per visit Diabetes Care Benefits Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for 20% testing supplies see outpatient prescription drug benefits) Diabetes self-management training $45 per visit Urgent Care Benefits (BlueCard Program) Urgent services outside your personal physician service area $90 per visit Optional Benefits Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is provided separately. Pediatric Vision Benefits Comprehensive Eye Exam 12 : one per calendar year (includes dilation, if professionally indicated) Ophthalmologic - Routine ophthalmologic exam with refraction new patient (S0620) - Routine ophthalmologic exam with refraction established patient (S0621) Optometric - New patient exams (92002/92004) - Established patient exams (92012/92014) Eyeglasses Lenses: one pair per calendar year - Single vision (V2100-2199) - Conventional (Lined) bifocal (V2200-2299) - Conventional (Lined) trifocal (V2300-2399) - Lenticular (V2121, V2221, V2321) Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses. Optional Lenses and Treatments UV coating Anti-reflective coating $35 High-index lenses $30 Photochromic lenses - plastic $25 Photochromic lenses - glass $25 Polarized lenses $45 Standard progressives $55 Premium progressives $95 Frame 13 (one frame per calendar year) Collection frames Non-Collection frames Up to $150 Maximum Contact Lenses 14 Non-Elective (Medically Necessary) Hard or soft One pair per Calendar Year Elective (Cosmetic/Convenience) Standard hard (V2500, V2510) One pair per Calendar Year Elective (Cosmetic/Convenience) Non-standard hard (V2501-V2503, V2511-V2513, V2530- V2531) One pair per Calendar Year 50% 1 Health plans (HMO) Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 109
Elective (Cosmetic/Convenience) Standard soft (V2520) One pair per month, up to 6 months, per Calendar Year Elective (Cosmetic/Convenience) Non-standard soft (V2521-V2523) One pair per month, up to 3 months, per Calendar Year Other Pediatric Vision Benefits Supplemental low-vision testing and equipment 15 35% Diabetes management referral 1 Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the Summary of Benefits and Evidence of Coverage 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 or substance abuse services must be provided by a MHSA network participating provider. 3 Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory surgery center affiliated with a hospital, with payment according to the hospital services benefit. 4 Skilled nursing services are limited to 100 preauthorized days during a benefit period 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. 5 Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary. Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability. Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs. 6 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment. 7 Includes insertion of IUD as well as injectable contraceptives for women. 8 Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment may apply. 9 If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation. 10 This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium. 11 Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception. 12 The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses. 13 This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the frames as Collection but are required to maintain a comparable selection of frames that are covered in full. For non-collection frames the allowable amount is up to $150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory. 14 Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required. 15 A report from the provider and prior authorization from the contracted Vision Plan Administrator is required 16 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 Summary of Benefits and Evidence of Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers. Plan designs may be modified to ensure compliance with state and federal requirements. This plan is pending regulatory approval. 110 Benefit Summary Guide
Supplemental coverage at a glance We offer supplemental coverage for infertility treatment. This supplemental coverage can be purchased only with a Blue Shield of California PPO* or HSA-HDHP* health plan. If the group is offering multiple Blue Shield of California medical plan options to its employees, it must offer this supplemental coverage with all medical plan options. For example, if a group wishes to offer supplemental infertility coverage for its employees and currently offers one HSA-HDHP and two PPO plans, the group must offer the same supplemental infertility benefit for all three plans. Infertility coverage Available with all Blue Shield PPO and HSA-HDHP plans* This supplemental benefit covers infertility services,** which include procedures consistent with established medical practices, such as: Medication S u rg e r y Gamete intrafallopian transfer (GIFT) Cryopreservation The following procedures are limited per lifetime as shown: Six natural (without ovum [egg] stimulation) artificial inseminations Three stimulated (with ovum [egg] stimulation) artificial inseminations One gamete intrafallopian transfer (GIFT) Cryopreservation limited to one retrieval and one year of storage PPO and HSA-HDHP plan members have no lifetime maximum benefit limit for the diagnosis and treatment of the cause of infertility, including inducement of fertilization, and will be responsible for 50% of allowed charges for the covered procedures listed above. Please refer to the plan contract and the Evidence of Coverage (EOC) for a detailed description of covered benefits, limitations, and exclusions. * The additional infertility coverage is available with the following plans: Ultimate Full PPO for Small Business 0, Ultimate Full PPO for Small Business 150, Preferred Full PPO for Small Business 0, Preferred Full PPO for Small Business 750, Enhanced Full PPO for Small Business 1250, Enhanced Full PPO for Small Business 2000, Basic Full PPO for Small Business 4500, Basic Exclusive PPO for Small Business, Enhanced Full PPO for HSA for Small Business 2000, Enhanced Full PPO for HSA for Small Business 3500, and Basic Full PPO for HSA for Small Business 5500. ** Please note that in vitro fertilization (IVF), intracytoplasmic sperm injection (ICSI), and zygote intrafallopian transfer (ZIfT) are excluded services. Health plans Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 111
Specialty benefits Dental, vision, and life insurance plans Available with all Blue Shield plans Our dental, vision, and life insurance* benefits can help complete and enhance your employees health benefits package. These plans are available with or without a medical plan. To download specialty benefits plan summaries, go to blueshieldca.com/employer and select the specialty products you want to review from the left navigation bar. Form DE9C is not required when purchasing specialty products without a medical plan. Dental plans Blue Shield offers dental plans with a wide range of oral healthcare benefits at competitive rates. Groups with one or more eligible employees can take advantage of our dental plan coverage, when purchased with or without a Blue Shield medical plan. There are no employer contribution requirements for voluntary dental plans. All other dental plans require a minimum 50% employer contribution and 75% employee participation. Billing for dental coverage will be combined with the billing for the health plan coverage, when applicable. Members can search for dental network providers in the Find a Provider section of blueshieldca.com. The Blue Shield website for dental plans offers your employees easy access to comprehensive dental plan information at yourdentalplan.com/bsca. The website can help covered employees and their dependents save time, monitor claims and obtain helpful information on oral health care. 12 dental PPO plans Dental PPO plans offer members a range of benefit options. Key features and advantages include: Plans with orthodontic coverage offer a $1,000 calendar-year, not lifetime, maximum for both children and adults. 1 Choice of accessing care from participating or nonparticipating general and specialty dentists, although members save money by accessing care from participating dentist providers with over 25,000 provider locations in California and over 218,000 nationwide, 2 it s convenient to access dental care. Preventive and diagnostic services not subject to plan deductibles when accessed at network dentists. No waiting periods for covered services (except with voluntary plans 3 ). Dental implant benefit on Smile SM Deluxe 2000 and Smile Deluxe Plus 2000 plans. An enhanced oral cancer screening benefit to detect and treat oral cancer early, when the opportunity for cure is greater. Enhanced dental benefits for pregnant women. A third cleaning, root planing, and periodontal scaling are paid at 100% for pregnant women, reducing the chances of getting periodontal disease, which is also linked to premature delivery and low-birthweight babies. Dental Member Services is available to assist members toll-free at (888) 702-4171. Here s what our dental PPO plan names will tell you: Plan name deductible per person/calendar-year maximum/orthodontic coverage/out-of-network reimbursement level 1 Orthodontia benefits are included in the following Dental PPO Smile Plans: Smile Plus 50/1500/Ortho/MAC, Smile Plus Gold 50/1500/Ortho/ u85, Smile Deluxe 50/1500/Ortho/MAC, Smile Deluxe Plus 2000 50/2000/ Ortho/MAC, and Smile Deluxe Gold 50/1500/Ortho/u85. 2 Dental providers in and out of California are available through a contracted dental plan administrator. 3 Voluntary dental PPO and voluntary dental INO plans have a 12-month waiting period for major services. Voluntary dental INO plans also have a 12-month waiting period for orthodontia services. * Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). 112 Benefit Summary Guide
In-Network Only (INO) dental plans A Smile In-Network Only (INO) dental plan 1 network includes all the same providers as the dental PPO network. Members can access covered services from any provider in the INO network. 2 There is no coverage for services received outside of this network. The dental INO plan has four components. Employers select the options that best suit their business needs and budget: 1. Voluntary or contributory 3 2. Calendar-year benefit maximum ($1,500 or $2,500) 3. Endodontics and periodontics (surgical or complex) coverage level (50% or 80% coinsurance level) 4. Orthodontia coverage (include or exclude) Dental Member Services is available toll-free at (888) 702-4171. 1 Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). 2 Dental providers in and out of California are available through a contracted dental plan administrator. 3 Voluntary dental PPO and voluntary dental INO plans have a 12-month waiting period for major services. Voluntary dental INO plans also have a 12-month waiting period for orthodontia services. Dental HMO plans Dental HMO plans are designed to help members take more control of their dental costs while coordinating their family s dental care through a dental provider of their choice. Blue Shield s dental HMO plans Dental HMO Basic, Dental HMO Plus, and Dental HMO Deluxe offer basic, middle, and rich levels of benefits, respectively. Dental HMO Voluntary lets employers offer a dental plan with no minimum employer contribution requirements. Key plan features and advantages include: No charge for covered diagnostic and preventive services No waiting periods No plan deductibles No calendar-year maximums A full range of dental services with affordable, fixed copayments A large statewide network with more than 16,000 dental provider locations* Orthodontia benefits for both children and adults No claim forms to complete Assistance from Dental HMO Member Services available toll-free at (800) 585-8111 * Dental providers in and out of California are available through a contracted dental plan administrator. Health plans specialty benefits specialty Products General PLan Information Benefit Summary Guide 113
Dental PPO plan comparison chart Smile Basic Voluntary 1 75/1000/ No Ortho/MAC Smile Basic 75/1000/ No Ortho/MAC Smile Value 50/1500/ No Ortho/MAC Smile 50/1500/ No Ortho/MAC Smile Plus 50/1500/ Ortho/MAC Network Nonnetwork 4 Network Nonnetwork 4 Network Nonnetwork 4 Network Nonnetwork 4 Network Nonnetwork 4 Deductible $75/person $225/family $75/person $225/family $50/person $150/family $50/person $150/family $50/person $150/family Calendar-year maximum $1,000 ($750 may be used for non-network dentists) $1,000 ($750 may be used for non-network dentists) $1,500 ($750 may be used for nonnetwork dentists) $1,500 ($750 may be used for non-network dentists) $1,500 ($750 may be used for non-network dentists) Diagnostic and preventive care 5 (includes routine oral exams, X-rays, cleanings, and oral cancer screening) Enhanced dental benefits for pregnant women 6 (includes routine prophylaxis including prophylaxis for pregnancy gingivitis periodontal scaling and root planing, and periodontal maintenance) Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers) Endodontics, periodontics, and oral surgery Major services (includes crown buildups, crowns, prosthetics, onlays, jackets, posts, cores, and implants) Orthodontics all ages (up to $1,000 per calendar year in addition to the calendar-year maximum for the other covered services) 5 100% 50% 100% 50% 100% 80% 100% 80% 100% 80% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 50% 50% 50% 50% 80% 70% 80% 70% 80% 70% 50% 50% 50% 50% 50% 50% 80% 70% 80% 70% 50% 7 50% 7 50% 7 50% 7 50% 7 50% 7 50% 7 50% 7 50% 7 50% 7 Not covered Not covered Not covered Not covered 50% 50% 1 Smile Basic Voluntary 75/1000/No Ortho/MAC has a 12-month waiting period for major services. 2 For Blue Shield of California s Smile Plus Gold 50/1500/Ortho/ 85 and Smile Deluxe Gold 50/1500/Ortho/ 85 plans, the contracted dental plan administrator uses a different schedule of allowable amounts for non-network dentists than that used for network dentists. 3 If the member goes to a non-network dentist, reimbursement for a service by that non-network dentist may be less than the amount billed. 4 The coinsurance percentage indicated is a percentage of allowed amounts that Blue Shield pays to providers. Non-network providers can charge more than Blue Shield s allowable amount. When members use non-network providers, they must pay the applicable copayment/coinsurance plus any amount that exceeds Blue Shield s allowable amount. Charges in excess of the allowable amount do not count toward the calendar-year deductible or copayment maximum. 5 Not subject to plan deductibles with network or non-network dentists. 6 One additional routine adult prophylaxis (including periodontal prophylaxis for gingivitis) for women during pregnancy and one periodontal maintenance visit if warranted by a history of periodontal treatment and one course (up to four quadrants) of periodontal scaling and root planing for women during pregnancy with a documented existing periodontal condition. To obtain information about these benefits, including the unique address for submitting claims, please call (888) 702-4171. For treatment outside of a pregnancy, coverage is provided under Periodontics or Diagnostic and Preventive Care. 7 Implants are not a covered benefit of this plan. 114 Benefit Summary Guide
Dental PPO plan comparison chart Smile Plus Gold 50/1500/ Ortho/U85 2,3 Network $50/person $150/family Nonnetwork 4 $1,500 ($1,000 may be used for nonnetwork dentists) Smile Deluxe 2000 50/2000/ No Ortho/MAC Network $50/person $150/family Nonnetwork 4 $2,000 (may be used for both network and non-network dentists) Smile Deluxe 50/1500/ Ortho/MAC Network $50/person $150/family Nonnetwork 4 $1,500 (may be used for both network and non-network dentists) Smile Deluxe Plus 2000 50/2000/ Ortho/MAC Network $50/person $150/family Nonnetwork 4 $2,000 (may be used for both network and non-network dentists) Smile Deluxe Gold 50/1500/ Ortho/U85 2,3 Network $50/person $150/family Nonnetwork 4 $1,500 (may be used for both network and non-network dentists) Ultimate Dental Plus PPO for Small Business 50/2000 Network $50/person $150/family Nonnetwork 4 $2,000 (may be used for both network and non-network dentists) Ultimate Dental PPO for Small Business 50/2000 Network $50/person $150/family Nonnetwork 4 $2,000 (may be used for both network and non-network dentists) 100% 80% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 80% 70% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 90% 80% 50% 50% 80% 80% 80% 80% 80% 80% 80% 80% 80% 80% 90% 80% 50% 7 50% 7 50% 50% 50% 7 50% 7 50% 50% 50% 7 50% 7 60% 7 50% 7 60% 50% 50% 50% Not covered 50% 50% 50% 50% 50% 50% 80% 50% Not covered Health plans Supplemental Coverage specialty benefits General PLan Information Benefit Summary Guide 115
Dental INO (in-network only) plan comparison chart The Smile In-Network Only dental plan portfolio 1 provides a choice of options to help protect members oral health as well as employers bottom line. Groups can choose the benefit levels and funding option to achieve the right mix of cost with benefits. No benefits are paid if the member goes to non-network providers. Plan options 1. Choose how plan will be funded: employer-contributed or voluntary. 2. Choose among four benefit options for employees, as noted in the chart below: Plan Employer funding Calendar-year benefit maximum Endo-perio (surgical or complex) coinsurance Orthodontia Smile INO Dental Plan Contributory/voluntary $1,500/$2,500 Basic = 50%/Plus = 80% $1,000 annual maximum/none Here s what our dental INO plan names will tell you: If you chose contributory funding, $2,500 calendar-year benefit maximum, endo-perio plus, and include orthodontia, your plan name would be: Smile In-Network Only Plan $2500/Endo-Perio 80%/Ortho Summary of member-level benefits Employer funding options Contributory no waiting period Voluntary 12-month waiting period on major services and orthodontic services, if applicable (see below) Calendar-year deductible (applies to covered services other than $50 ($150/family) diagnostic and preventive services and enhanced dental benefits for pregnant women) Calendar-year Benefit maximum payment $2,500 (charges for services above the maximum are your responsibility) $1,500 $2,500 Blue Shield pays network provider Service Basic Plus Diagnostic and preventive care (includes routine oral exams, X-rays, cleanings, and oral cancer screening) 100% 100% Basic services (includes anesthesia, emergency treatment to relieve pain, restorative dentistry, sealants, space maintainers, oral surgery) 80% 80% Endo-perio (non-surgical and non-complex) benefit options 80% 80% Endo-perio (surgical and complex) benefit options (must match options chosen in Step 2 above) 50% 80% Major services (includes crown buildups, crowns, prosthetics, onlays, jackets, and posts and cores) 2 50% 50% Orthodontics benefit options (if applicable) all ages (up to $1,000 per calendar year) (must match option chosen in Step 2 above) Covered Not covered Enhanced dental benefits for pregnant women (includes routine prophylaxis including prophylaxis for pregnancy gingivitis periodontal scaling and root planing, and periodontal maintenance) 1 Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). 2 Implants are not a covered benefit of the plan. 50% 0% 50% 0% 100% 100% 116 Benefit Summary Guide
Dental HMO plan comparison chart ADA code ADA description Office visit Dental HMO Basic What members pay Dental HMO Plus Dental HMO Deluxe Dental HMO Voluntary Office visit $5 $5 $5 $5 Diagnostic services (exams and X-rays) D0120 Periodic oral evaluation established patient $0 $0 $0 $0 D0140 Limited oral evaluation problem focused $0 $0 $0 $0 D0145 D0150 Oral evaluation for a patient under 3 years of age and counseling with primary caregiver Comprehensive oral evaluation new or established patient D0160 Detailed and extensive oral evaluation problem focused, by report D0170 Re-evaluation limited, problem focused (not post-operative visit) $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 D0180 Comprehensive periodontal evaluation $0 $0 $0 $0 D0190 Screening of a patient $0 $0 $0 $0 D0191 Assessment of a patient $0 $0 $0 $0 D0210 Intraoral complete series (including bitewings) $0 $0 $0 $0 D0220 Intraoral periapical first film $0 $0 $0 $0 D0230 Intraoral periapical each additional film $0 $0 $0 $0 D0240 Intraoral occlusal film $0 $0 $0 $0 D0270 Bitewing single film $0 $0 $0 $0 D0272 Bitewings two films $0 $0 $0 $0 D0273 Bitewings three films $0 $0 $0 $0 D0274 Bitewings four films $0 $0 $0 $0 D0330 Panoramic film $0 $0 $0 $0 D0460 Pulp vitality tests $0 $0 $0 $0 D0470 Diagnostic casts $0 $0 $0 $0 D9310 Consultation - diagnostic service provided by dentist or physician other than requesting dentist or physician Preventive (cleanings and fluoride) $0 $0 $0 $0 D1110 Prophylaxis adult $0 $0 $0 $0 D1110 Additional adult prophylaxis within the 6-month period, i.e., third cleaning $45 $45 $45 $45 D1120 Prophylaxis child $0 $0 $0 $0 D1120 Additional child prophylaxis within the 6-month period, i.e., third cleaning $35 $35 $35 $35 D1206 Topical fluoride varnish (covered through age 17) $0 $0 $0 $0 D1208 Topical application of fluoride child <=16 $0 $0 $0 $0 D1330 Oral hygiene instruction $0 $0 $0 $0 D1351 Sealant per tooth $0 $0 $0 $0 D1352 Preventive resin restoration in a moderate to high caries risk patient permanent tooth $0 $0 $0 $0 D1510 Space maintainer fixed unilateral $40 $10 $5 $20 D1515 Space maintainer fixed bilateral $40 $10 $5 $20 Health plans Supplemental Coverage specialty benefits General PLan Information Benefit Summary Guide 117
Dental HMO plan comparison chart ADA code ADA description Dental HMO Basic What members pay Dental HMO Plus Dental HMO Deluxe Dental HMO Voluntary D1520 Space maintainer removable unilateral $40 $10 $5 $20 D1525 Space maintainer removable bilateral $40 $10 $5 $20 D1550 Re-cementation of space maintainer $40 $10 $5 $20 D1555 Removal of fixed space maintainer $20 $10 $0 $15 Minor restorative services (includes local anesthetic) D2140 Amalgam one surface, primary or permanent $20 $10 $0 $15 D2150 Amalgam two surfaces, primary or permanent $40 $20 $0 $30 D2160 D2161 Amalgam three surfaces, primary or permanent Amalgam four or more surfaces, primary or permanent $60 $30 $0 $45 $80 $40 $0 $60 D2330 Resin-based composite one surface, anterior $20 $10 $0 $15 D2331 Resin-based composite two surfaces, anterior $40 $20 $0 $30 D2332 Resin-based composite three surfaces, anterior $60 $30 $0 $45 D2335 Resin-based composite four or more surfaces or involving incisal angle, anterior $80 $40 $0 $60 D2390 Resin-based composite crown, anterior $150 $150 $150 $150 D2391 Resin-based composite one surface, posterior $75 $64 $61 $71 D2392 Resin-based composite two surfaces, posterior $90 $76 $72 $85 D2393 Resin-based composite three surfaces, posterior $115 $98 $93 $109 D2394 Resin-based composite four or more surfaces, posterior Major restorative services (includes local anesthetic) $140 $120 $114 $133 D2542 Onlay metallic two surfaces $325 $125 $125 $225 D2543 Onlay metallic three surfaces $325 $125 $125 $225 D2544 Onlay metallic four or more surfaces $325 $125 $125 $225 D2642 Onlay porcelain/ceramic two surfaces $390 $310 $250 $350 D2643 D2644 Onlay porcelain/ceramic three or more surfaces Onlay porcelain/ceramic four or more surfaces $410 $325 $260 $370 $430 $340 $275 $390 D2662 Onlay resin-based composite two surfaces $330 $270 $215 $300 D2663 Onlay resin-based composite three surfaces $350 $285 $225 $320 D2664 Onlay resin-based composite four or more surfaces $380 $305 $245 $345 D2710 Crown resin-based composite (indirect) $210 $210 $165 $210 D2720 Crown resin with high noble metal $395 $325 $260 $360 D2721 Crown resin with predominantly base metal $330 $260 $195 $290 D2722 Crown resin with noble metal $360 $290 $225 $320 D2740 Crown porcelain/ceramic substrate 1 $350 $150 $125 $250 D2750 Crown porcelain fused to high noble metal 1 $350 $150 $125 $250 D2751 Crown porcelain fused to predominantly base $350 $150 $125 $250 metal 1 D2752 Crown porcelain fused to noble metal 1 $350 $150 $125 $250 D2780 Crown 3/4 cast high noble metal 1 $350 $150 $125 $250 118 Benefit Summary Guide
Dental HMO plan comparison chart ADA code ADA description Dental HMO Basic What members pay Dental HMO Plus Dental HMO Deluxe Dental HMO Voluntary D2781 Crown 3/4 cast predominantly base metal 1 $350 $150 $125 $250 D2782 Crown 3/4 cast noble metal 1 $350 $150 $125 $250 D2783 Crown 3/4 porcelain/ceramic 1 $350 $150 $125 $250 D2790 Crown full cast high noble metal 1 $350 $150 $125 $250 D2791 Crown full cast predominantly base metal 1 $350 $150 $125 $250 D2792 Crown full cast noble metal 1 $350 $150 $125 $250 D2910 Recement inlay, onlay, or partial coverage restoration $45 $18 $9 $36 D2915 Recement cast or prefabricated post and core $45 $19 $10 $38 D2920 Recement crown $15 $5 $5 $10 D2930 D2931 Prefabricated stainless steel crown primary tooth Prefabricated stainless steel crown permanent tooth $30 $10 $5 $20 $95 $35 $15 $65 D2932 Prefabricated resin crown $100 $40 $25 $70 D2933 D2934 Prefabricated stainless steel crown with resin window primary tooth Prefabricated esthetic coated stainless steel crown - primary tooth child <=7 $100 $100 $40 $20 $70 $100 $40 $20 $70 D2940 Protective restoration $48 $19 $10 $38 D2950 Core buildup, including any pins $118 $47 $24 $60 D2951 D2952 D2953 Pin retention per tooth in addition to restoration Post and core in addition to crown, indirectly fabricated Each additional indirectly fabricated post, same tooth $25 $10 $5 $20 $165 $72 $36 $144 $125 $50 $25 $100 D2954 Prefabricated post and core in addition to crown $140 $59 $30 $117 D2955 Post removal $0 $0 $0 $0 D2957 Each additional prefabricated post same tooth $78 $32 $16 $63 D2980 Crown repair, by report $121 $49 $25 $97 D2981 D2982 Inlay repair necessitated by restorative material failure Onlay repair necessitated by restorative material failure Endodontic services (includes local anesthetic) D3110 Pulp cap (direct) excluding final restoration $20 $5 $0 $15 D3120 Pulp cap (indirect) excluding final restoration $20 $5 $0 $15 D3220 D3221 D3310 Therapeutic pulpotomy (excluding final restoration) removal of pulp coronal to the dentinocemental junction and application of medicament Pulpal debridement primary and permanent tooth Endodontic therapy anterior tooth (excluding final restoration) $35 $10 $5 $30 $60 $20 $10 $40 $175 $75 $50 $125 Health plans Supplemental Coverage specialty benefits General PLan Information Benefit Summary Guide 119
Dental HMO plan comparison chart ADA code ADA description D3320 D3330 D3331 D3332 Endodontic therapy bicuspid tooth (excluding final restoration) Endodontic therapy molar tooth (excluding final restoration) Treatment of root canal obstruction; non-surgical access Incomplete endodontic therapy; inoperable, unrestorable or fractured tooth Dental HMO Basic What members pay Dental HMO Plus Dental HMO Deluxe Dental HMO Voluntary $250 $130 $80 $175 $355 $210 $145 $225 $40 $30 $25 $35 $130 $115 $40 $125 D3346 Retreatment of previous root canal anterior $175 $75 $50 $125 D3347 Retreatment of previous root canal bicuspid $350 $105 $70 $175 D3348 Retreatment of previous root canal molar $525 $135 $90 $225 D3410 Apioectomy/periradicular surgery anterior $75 $30 $20 $50 D3421 Apioectomy/periradicular surgery bicuspid, first root $75 $30 $20 $50 D3425 Apioectomy/periradicular surgery molar, first root $75 $30 $20 $50 D3426 Apioectomy/periradicular surgery molar, each additional root $75 $30 $20 $50 D3430 Retrograde filling per root $113 $45 $23 $90 D3450 Root amputation per root $125 $50 $100 $100 D3920 D3950 Hemisection (including any root removal; not including root canal therapy) Canal preparation and fitting of performed dowel post Periodontic services (includes local anesthetic) D4210 D4211 D4212 D4240 D4241 D4260 D4261 Gingivectomy/gingivoplasty four or more contiguous teeth or tooth bounded spaces per quadrant Gingivectomy/gingivoplasty one to three contiguous teeth or tooth bounded spaces per quadrant Gingivectomy/gingivoplasty to allow access for restorative procedure, per tooth Gingival flap procedure including root planing four or more teeth per quadrant Gingival flap procedure including root planing one to three teeth per quadrant Osseous surgery (including flap entry and closures) four or more contiguous teeth or tooth bounded spaces per quadrant Osseous surgery (including flap entry and closures) one to three contiguous teeth or tooth bounded spaces per quadrant $125 $50 $25 $100 $0 $0 $0 $0 $200 $100 $75 $150 $40 $20 $15 $30 $0 $0 $0 $0 $190 $150 $125 $190 $138 $175 $63 $113 $275 $150 $125 $225 $138 $75 $63 $113 D4263 Bone replacement graft first site in quadrant $275 $115 $58 $230 D4264 D4266 D4267 Bone replacement graft each additional site in quadrant Guided tissue regeneration resorbable barrier, per site Guided tissue regeneration nonresorbable barrier, per site (includes membrane removal) $135 $85 $43 $135 $215 $143 $72 $215 $225 $165 $83 $250 120 Benefit Summary Guide
Dental HMO plan comparison chart ADA code ADA description Dental HMO Basic What members pay Dental HMO Plus Dental HMO Deluxe Dental HMO Voluntary D4270 Pedicle soft tissue graft procedure $350 $140 $70 $280 D4273 D4276 D4277 D4278 D4341 D4342 D4355 D4381 Subepithelial connective tissue graft procedure per tooth Combination connective tissue and double pedicle graft per tooth Free soft tissue graft procedure (including donor site surgery) first tooth Free soft tissue graft procedure (including donor site surgery) Periodontal scaling and root planing four or more teeth per quadrant Periodontal scaling and root planing one to three teeth per quadrant full mouth debridement to enable comprehensive evaluation and diagnosis Localized delivery of antimicrobial agents via a controlled release vehicle into diseased crevicular tissue, per tooth, by report $450 $180 $90 $360 $463 $185 $93 $370 $375 $150 $75 $300 $225 $90 $45 $180 $75 $20 $10 $40 $38 $10 $5 $20 $75 $20 $10 $40 $48 $13 $6 $26 D4910 Periodontal maintenance $45 $20 $5 $30 Removable prosthetic services (includes local anesthetic) D5110 Complete denture maxillary $400 $175 $100 $250 D5120 Complete denture mandibular $400 $175 $100 $250 D5130 Immediate denture maxillary $400 $175 $100 $250 D5140 Immediate denture mandibular $400 $175 $100 $250 D5211 D5212 D5213 D5214 D5225 D5226 D5281 Maxillary partial denture resin base (including $400 $200 $175 $275 any conventional clasps, rests, and teeth) 1 Mandibular partial denture resin base (including $400 $200 $175 $275 any conventional clasps, rests, and teeth) 1 Maxillary partial denture cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1 Mandibular partial denture cast metal framework with resin denture bases (including any conventional clasps, rests, and teeth) 1 $400 $200 $175 $275 $400 $200 $175 $275 Maxillary partial denture flexible base $400 $200 $175 $275 (including any clasps, rests, and teeth) 1 Mandibular partial denture flexible base $400 $200 $175 $275 (including any clasps, rests, and teeth) 1 Removalble unilateral partial denture one $400 $200 $175 $275 piece cast metal (including clasps and teeth) 1 D5410 Adjust complete denture maxillary $0 $0 $25 $0 D5411 Adjust complete denture mandibular $0 $0 $25 $0 D5421 Adjust partial denture maxillary $40 $40 $25 $0 D5422 Adjust partial denture mandibular $40 $40 $25 $40 D5510 repair broken complete denture base $85 $75 $25 $85 D5520 replace missing or broken teeth complete denture (each tooth) $75 $75 $25 $100 D5610 Repair resin denture base $95 $75 $25 $100 Health plans Supplemental Coverage specialty benefits General PLan Information Benefit Summary Guide 121
Dental HMO plan comparison chart ADA code ADA description Dental HMO Basic What members pay Dental HMO Plus Dental HMO Deluxe Dental HMO Voluntary D5620 Repair cast framework $100 $75 $25 $100 D5630 Repair or replace broken clasp $100 $75 $25 $100 D5640 Replace broken teeth per tooth $75 $75 $25 $100 D5650 Add tooth to existing partial denture $85 $50 $25 $75 D5660 Add clasp to existing partial denture $85 $50 $25 $85 D5670 Replace all teeth and acrylic on cast framework maxillary D5671 Replace all teeth and acrylic on cast framework mandibular $270 $120 $105 $165 $270 $120 $105 $165 D5710 Rebase complete maxillary denture $125 $50 $25 $100 D5711 Rebase complete mandibular denture $125 $50 $25 $100 D5720 Rebase maxillary partial denture $125 $50 $25 $100 D5721 Rebase mandibular partial denture $125 $50 $25 $100 D5730 Reline complete maxillary denture (chairside) 2 $125 $50 $25 $100 D5731 Reline complete mandibular denture (chairside) 2 $125 $50 $25 $100 D5740 Reline maxillary partial denture (chairside) 2 $125 $50 $25 $100 D5741 Reline mandibular partial denture (chairside) 2 $125 $50 $25 $100 D5750 Reline complete maxillary denture (laboratory) 2 $150 $75 $50 $125 D5751 Reline complete mandibular denture (laboratory) 2 $150 $75 $50 $125 D5760 Reline maxillary partial denture (laboratory) 2 $150 $75 $50 $125 D5761 Reline mandibular partial denture (laboratory) 2 $150 $75 $50 $125 D5850 Tissue conditioning maxillary $30 $10 $5 $20 D5851 Tissue conditioning mandibular $30 $10 $5 $20 Fixed prosthodontic services (includes local anesthetic) D6205 Pontic indirect resin-based composite 1 $310 $150 $125 $250 D6210 Pontic cast high noble metal 1 $350 $150 $125 $250 D6211 Pontic cast predominantly base metal 1 $350 $150 $125 $250 D6212 Pontic cast noble metal 1 $350 $150 $125 $250 D6214 Pontic cast titanium metal 1 $350 $150 $125 $250 D6240 Pontic porcelain fused to high noble metal 1 $350 $150 $125 $250 D6241 Pontic porcelain fused to predominantly base $350 $150 $125 $250 metal 1 D6242 Pontic porcelain fused to noble metal 1 $350 $150 $125 $250 D6245 Pontic porcelain/ceramic 1 $350 $150 $125 $250 D6250 Pontic resin with high noble metal 1 $350 $150 $125 $250 D6251 Pontic resin with predominantly base metal 1 $350 $150 $125 $250 D6252 Pontic resin with noble metal 1 $350 $150 $125 $250 D6545 D6548 Retainer cast metal for resin-bonded fixed $150 $150 $125 $250 prosthesis 1 Retainer porcelain/ceramic for resin-bonded $215 $150 $125 $215 fixed prosthesis 1 D6608 Onlay porcelain/ceramic two surfaces 1 $350 $150 $125 $250 D6609 Onlay porcelain/ceramic three or more $350 $150 $125 $250 surfaces 1 122 Benefit Summary Guide
Dental HMO plan comparison chart ADA code ADA description Dental HMO Basic What members pay Dental HMO Plus Dental HMO Deluxe Dental HMO Voluntary D6610 Onlay cast high noble metal two surfaces 1 $350 $150 $125 $250 D6611 D6612 D6613 Onlay cast high noble metal three or more $350 $150 $125 $250 surfaces 1 Onlay cast predominantly base metal two $350 $150 $125 $250 surfaces 1 Onlay cast predominantly base metal three $350 $150 $125 $250 or more surfaces 1 D6614 Onlay cast noble metal two surfaces 1 $350 $150 $125 $250 D6615 Onlay cast noble metal three or more $350 $150 $125 $250 surfaces 1 D6710 crown indirect resin-based composite 1 $350 $150 $125 $250 D6720 crown resin with high noble metal 1 $350 $150 $125 $250 D6721 crown resin with predominantly base metal 1 $350 $150 $125 $250 D6722 crown resin with noble metal 1 $350 $150 $125 $250 D6740 crown porcelain/ceramic 1 $350 $150 $125 $250 D6750 crown porcelain fused to high noble metal 1 $350 $150 $125 $250 D6751 crown porcelain fused to predominantly base $350 $150 $125 $250 metal 1 D6752 crown porcelain fused to noble metal 1 $350 $150 $125 $250 D6780 crown 3/4 cast high noble metal 1 $350 $150 $125 $250 D6781 crown 3/4 cast predominantly base metal 1 $350 $150 $125 $250 D6782 crown 3/4 cast noble metal 1 $350 $150 $125 $250 D6783 crown 3/4 porcelain/ceramic 1 $350 $150 $125 $250 D6790 crown full cast high noble metal 1 $350 $150 $125 $250 D6791 crown full cast predominantly base metal 1 $350 $150 $125 $250 D6792 crown full cast noble metal 1 $350 $150 $125 $250 D6930 Recement fixed partial denture $30 $10 $0 $20 D6970 D6972 Post and core in addition to fixed partial denture $125 $75 $50 $100 retainer, indirectly fabricated 1 Prefabricated post with core buildup in addition to fixed denture retainer $100 $50 $25 $100 D6973 Core buildup for retainer, including any pins $100 $48 $25 $96 D6976 Each additional indirectly fabricated post same tooth $125 $75 $50 $100 D6977 Each additional prefabricated post same tooth 1 $100 $50 $25 $100 D6980 Fixed partial denture repair, by report $30 + lab $10 + lab $5 + lab $20 + lab Oral surgery services (includes local anesthetic) D7111 Extraction of coronal remnants deciduous tooth $20 $5 $3 $10 D7140 D7210 Extraction, erupted tooth, or exposed root (elevation and/or forceps removal) Surgical removal of erupted tooth requiring removal of bone and/or sectioning of tooth, and including elevation of mucoperiosteal flap if indicated $40 $11 $6 $23 $75 $25 $15 $45 D7220 Removal of impacted tooth soft tissue $100 $30 $20 $50 D7230 Removal of impacted tooth partial bony $150 $50 $40 $75 Health plans Supplemental Coverage specialty benefits General PLan Information Benefit Summary Guide 123
Dental HMO plan comparison chart ADA code ADA description Dental HMO Basic What members pay Dental HMO Plus Dental HMO Deluxe Dental HMO Voluntary D7240 Removal of impacted tooth complete bony $225 $75 $65 $95 D7241 Removal of impacted tooth complete bony with unusual surgical complications $250 $75 $65 $95 D7250 Surgical removal of residual tooth roots $75 $40 $30 $60 D7251 Coronectomy - intentional partial tooth removal $94 $50 $38 $75 D7260 Oroantral fistula closure $350 $140 $70 $280 D7285 Biopsy of oral tissue - hard (bone, tooth) $76 $25 $13 $51 D7286 Biopsy of oral tissue soft 3 $60 $20 $10 $40 D7287 Exfoliative cytological sample collection $60 $10 $10 $40 D7288 Brush biopsy transepithelial sample collection $30 $10 $5 $20 D7310 Alveoloplasty in conjunction with extractions four or more teeth or tooth spaces, per quadrant D7311 Alveoloplasty in conjunction with extractions one to three teeth or tooth spaces, per quadrant D7320 Alveoloplasty not in conjunction with extractions four or more teeth or tooth spaces, per quadrant D7321 Alveoloplasty not in conjunction with extractions one to three teeth or tooth spaces, per quadrant $75 $40 $38 $60 $38 $20 $10 $30 $75 $40 $30 $60 $38 $20 $15 $30 D7471 Removal of lateral exostosis (maxilla or mandible) $263 $105 $53 $210 D7472 Removal of torus palatinus $315 $126 $63 $252 D7473 Removal of torus mandibularis $300 $120 $60 $240 D7510 Incision & drainage of abscess intraoral soft tissue $98 $39 $20 $78 D7511 D7550 D7960 Incision & drainage of abscess intraoral soft tissue complicated (includes drainage of multiple facial spaces) Partial ostectomy /sequestrectomy for removal of non-vital bone Frenulectomy also known as frenectomy orfrenotomy separate procedure not incidental to another procedure $139 $56 $28 $111 $170 $87 $44 $174 $188 $75 $38 $150 D7963 Frenuloplasty $205 $82 $41 $164 D7970 Excision of hyperplastic tissue per arch $125 $85 $43 $125 D7971 Excision of pericoronal gingival $100 $40 $20 $80 D7972 Surgical reduction of fibrous tuberosity $301 $120 $60 $241 Orthodontic services: Orthodontic treatment to correct malocclusion, limited to one continuous two-year course of treatment per employee, spouse, and eligible child through age 18 4 D8070 D8080 D8090 Comprehensive orthodontic treatment of the $2,350 $1,400 $1,200 $1,800 transitional dentition 5 Comprehensive orthodontic treatment of the $2,350 $1,400 $1,200 $1,800 adolescent dentition 5 Comprehensive orthodontic treatment of the $2,650 $1,700 $1,500 $2,650 adult dentition 5 D8210 Removable appliance therapy $360 $360 $360 $360 D8220 Fixed appliance therapy $406 $406 $406 $406 D8660 Pre-orthodontic treatment visit $250 $250 $250 $250 D8670 Periodic orthodontic treatment visit (as part of contract) $0 $0 $0 $0 124 Benefit Summary Guide
Dental HMO plan comparison chart ADA code ADA description D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s) Dental HMO Basic What members pay Dental HMO Plus Dental HMO Deluxe Dental HMO Voluntary $250 $250 $250 $250 D8660 Pre-orthodontic treatment visit $0 $0 $0 $0 D8680 Orthodontic retention (removal of appliances, construction and placement of retainer(s)) $125 $75 $50 $125 D8691 Repair of orthodontic appliance $88 $88 $88 $88 Adjunctive general services D9110 Palliative (emergency) treatment of dental pain minor procedure $20 $20 $20 $20 D9120 Fixed partial denture sectioning $37 $37 $37 $37 D9210 Local anesthesia not in conjunction with outpatient surgical procedures $0 $0 $0 $0 D9211 Regional block anesthesia $0 $0 $0 $0 D9212 Trigeminal division block anesthesia $0 $0 $0 $0 D9215 Local anesthesia in conjunction with outpatient surgical procedures D9220 Deep sedation/general anesthesia first 30 minutes D9221 D9241 Deep sedation/general anesthesia each additional 15 minutes Intravenous conscious sedation/analgesia first 30 minutes D9242 Intravenous conscious sedation/analgesia each additional 15 minutes D9430 Office visit for observation (during regularly scheduled hours) no other services performed $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $0 $15 $9 $6 $12 D9440 Office visit after regularly scheduled hours $40 $40 $40 $40 D9910 Application of desensitizing medicament $0 $0 $10 $0 D9940 Occlusal guards, by report $245 $98 $80 $196 D9942 Repair and/or reline of occlusal guard $45 $40 $40 $45 D9951 Occlusal adjustment limited $60 $50 $25 $60 D9952 Occlusal adjustment complete $125 $50 $25 $125 Other D9999 Unspecified adjunctive procedure, by report includes failed appointment (without 24-hour notice) per 15 minutes of appointment time $20 $20 $20 $25 1 Precious metals, if used, will be charged to the member at the dentist s cost. 2 Denture relines if done within six (6) months of the initial insertion of a denture are considered part of the original denture service and are included in the denture copayment; denture relines after six (6) months of the initial insertion of a denture require the additional denture reline copayment. 3 Subscriber pays lab fees for biopsies and excisions. 4 Note: In order to be covered, orthodontic treament: 1) Must be received in one continuous course of treatment; 2) Must be received in consecutive months; and 3) Must not exceed 24 consecutive months. 5 Full case fee includes consultation, treatment plan, tooth movement and retention. Orthodontist may charge members separately for records, limited to $250 per case. 6 The orthodontic benefit is subject to all plan limitations. Health plans Supplemental Coverage specialty benefits General PLan Information Benefit Summary Guide 125
Vision plans Blue Shield streamlines your vision plan choice selection into three simple easy steps. 1. Pick the frequency of frames and lens benefit coverage,12 or 24 months. 2. Decide if exam and materials copayments are cost-effective for your employees. 3. Determine the level of frame and contact lens allowances your employees need. With the rising cost of eyewear, Blue Shield is offering richer benefits at competitive rates. Groups of one or more eligible employees can combine any of our vision plans with a Blue Shield medical plan new for 2014. Vision plans require a 25% employer contribution, except with any of three new voluntary vision plans. Vision plan highlights: Plans with and without copayments for eye exams so you can control your expenses. New contact lens plans maximize eyewear coverage for your employees. Coverage includes not only a $120 elective contact lens allowance but also the selected frame allowance. These plans also expand standard comprehensive exam benefits to include standard contact lens fittings and evaluations. Access to retail providers with convenient evening and weekend hours including Costco (warehouse, membership required), Wal-Mart (wholesale), LensCrafters, Target Optical, Sears, Site for Sore Eyes, and For Eyes Optical, plus 24/7 access to online vision benefits at my2020eyesdirect.com for eyeglasses or MESVisionOptics.com for contact lenses. Three new voluntary vision plans with no minimum employer contribution requirements and a minimum of three enrolling employees. Polycarbonate lenses covered for enrolled dependent children. With over 6,300 ophthalmologist, optometrist, and optician provider locations in the contracted vision plan administrator s California network, and over 20,000 provider locations nationwide, it s convenient for members to access vision care. Vision plans with $150 frame allowance also include coverage for the most popular lens enhancements: progressive lenses, photochromic lenses, and anti-reflective coating. Low out-of-pocket expenses when members use a network provider. Out-of-network care is also available from any vision care provider, based on our schedule of out-of-network benefit limits members are responsible for any costs above allowable amounts. Find a vision provider at blueshieldca.com. To find providers outside California, visit blueshieldcavision.com. Vision Member Services is available toll-free at (877) 601-9083 or at blueshieldcavision.com. 126 Benefit Summary Guide
All vision plans include the following benfits Service and eyewear Coverage when provided by network providers after applicable copay Maximum benefit when provided by non-network providers Annual examination every 12 months Ophthalmologic exam 100% $60 Optometric exam 100% $50 Standard lenses1 every 12 or 24 months 2 Single-vision 100% $43 Bifocal 100% $60 Trifocal 100% $75 Aphakic/lenticular monofocal 100% $120 Aphakic/lenticular multifocal 100% $200 Lens Options Polycarbonate lenses for dependent children Up to $100 $75 Standard frame every 12 or 24 months Frame Up to $120 or $1504 depending on the $40 plan selected Contact lenses 5 every 12 or 24 2 months Non-elective, medically necessary 6 Hard 100% $200 Soft 100% $250 Elective Cosmetic or convenience (hard/soft) 9 Up to $120 Up to a maximum of $80 Other vision benefits Low-vision testing and equipment covered 75% coverage Not covered up to $1,000 7 Plano sunglasses 5,8 Up to $120 or $1504 depending on the Not covered plan selected Diabetes management referral 100% Not covered Additional benefits available on plans with $150 frame allowance All benefits stated above plus the following: Lens options Progressive (no-line bifocals) Up to $140 $100 Anti-reflective coating Up to $50 $35 Photochromic lenses Up to $160 $115 Single vision Up to $115 $85 Bifocal Up to $130 $95 Trifocal Up to $150 $110 Progressive Up to $200 $150 Polycarbonate photochromic lenses for dependent children in lieu of standard lenses Up to $160 $115 Additional benefits available on all Ulitimate, Preferred and Enhanced Plus Plans All benefits stated above plus the following: Contact lenses every 12 or 24 months 2 Standard contact lens fitting and evaluation 100% Not covered Elective Cosmetic or convenience (hard/soft) Up to $50 Up to a maximum of $120 in lieu of glasses How to read our vision plan names Vision plan names include numerals that correlate to dollar amounts for the eye exam copayment, materials copayment (lenses, frames, and low-vision aids), and frame allowance. For example, the Preferred Vision 15/25/120 plan offers a $15 eye exam copayment, $25 copayment for materials, and a $120 frame allowance. Health plans Supplemental Coverage specialty benefits General PLan Information Benefit Summary Guide 127
Enhanced Vision, Preferred Vision, and Ultimate Vision plans from Blue Shield Life Groups with one or more eligible employees can take advantage of these plans that can be purchased with or without a medical plan. Plan name Enhanced Vision 0/0/120 Enhanced Vision 0/0/150 Enhanced Vision Plus 0/0/150/120 Enhanced Vision 15/25/120 Enhanced Vision 15/25/150 Enhanced Vision Plus 15/25/150/120 Enhanced Vision Voluntary 15/25/120 10 Preferred Vision 0/0/120 Preferred Vision 0/0/150 Preferred Vision Plus 0/0/150 /120 Preferred Vision 15/25/120 Preferred Vision 15/25/150 Preferred Vision Plus 15/25/150/120 Preferred Vision Voluntary 15/25/120 10 Ultimate Vision 0/0/120 Ultimate Vision 0/0/150 Ultimate Vision Plus 0/0/150/120 Ultimate Vision 15/25/120 Ultimate Vision 15/25/150 Ultimate Vision Plus 15/25/150/120 Ultimate Vision Voluntary 15/25/150 10 Frequency of covered benefits Eye examination every 12 months Eye examination every 12 months Eye examination every 12 months Eyeglass or contact 5 lenses every 24 2 months or 12 months with a qualified prescription change Eyeglass or contact 5 lenses every 12 months Eyeglass or contact 5 lenses every 12 months Standard frame every 24 months Standard frame every 24 months Standard frame every 12 months 1 Fit any frame with an eye size less than 61 mm. 2 A change in standard lenses (excludes unusual lenses, such as oversize, no-line bifocal, or a material other than ordinary plastic) or contact lenses is permitted per 12-month period if required by qualified prescription change. A change in prescription of 0.50 diopters or more in one or both eyes; a shift in axis of astigmatism of 12 degrees; or a difference in vertical prism greater than 1 prism diopter; or a change in lens type. 3 Available for the plans with $130 or higher frame allowance only. 4 When the network provider uses wholesale or warehouse pricing, the maximum allowable frame allowance will be as follows: wholesale allowance ($66.04 to $99.06) and warehouse allowance ($69.09 to $103.64). Note that this pricing replaces the frame allowance shown in the Summary of Benefits ($120 to $150). If a more expensive frame is selected at a provider location that uses wholesale or warehouse pricing, the member is responsible for the additional cost above the wholesale or warehouse allowance. Network providers using wholesale pricing are identified in the Directory of Network Vision Providers. Any cost over the allowable amount is the employee s responsibility. 5 For Vision Plus plans, both contact lenses and eyeglass lenses and frames are covered during the benefit period. In all other plans, contact lens benefit is in lieu of eyeglass lenses and frame. 6 Prior authorization from a contracted vision plan administrator is required. 7 Any cost over $120 is the employee s responsibility. Members may apply contact lens fitting fees to the contact lens allowance. 8 A report from the provider and prior authorization from a contracted vision plan administrator is required. 9 In lieu of lenses and frames, or contacts. for members who have had PRK, LASIK, or custom LASIK vision correction surgery only, this benefit of plano sunglasses allowance is equal to the plan s frame allowance. An eye exam by a network provider is required to verify laser surgery or a note from the surgeon who performed the laser surgery is required to verify laser surgery. 10 Available to groups who have a minimum of three enrolling employees. 128 Benefit Summary Guide
LASIK discount program 1 LASIK and PRK correction surgery, an alternative to contacts or glasses, is one of the fastest-growing vision treatments. The discount program gives covered vision plan members access to: A 15% discount through the NVision Laser Eye Center provider network in California, or A 20% discount through the QualSight provider network in California and Nationwide. Discount Vision Program 1 Vision plan members can receive a 20% discount off the published retail prices when they use a participating California provider in the Discount Vision Program network for these services and supplies: Routine eye examinations Tints and coatings Frames and lenses Extra pair of glasses Photochromic lenses Non-prescription sunglasses Hard contact lenses Accessing your vision benefits is easy, just follow these steps: 1. Prior to receiving a service, review your benefit information outlined in the chart on the previous page. 2. Call and make an appointment with a network provider. 3. Alternatively, log in to My2020EyesDirect.com or mesvisionoptics.com to access the online network provider to purchase eyeglasses and contact lenses online using your benefits. Note, if you choose to take the frames you purchased online to your preferred eye care provider for adjustments you may incur a fitting or adjustment fee which is not covered under your vision benefit plan. Or: If you use a non-network provider, you re required to pay the provider s bill at the time of service. You can get reimbursement by obtaining a claim form by logging in to blueshieldca.com. Click on Member Forms and select the Vision Benefit Claim form link. Complete and submit the claim form with the itemized receipt and a copy of your prescription to: Blue Shield of California Life & Health Insurance Company P.O. Box 25208 Santa Ana, CA 92799-5208 You will be reimbursed for your expenses up to the maximum payment allowed (see table on previous page). Note that when your dependents submit a claim form for reimbursement, payment will be made to you. Be sure to use your Blue Shield member identification number when filling out the form. Your vision coverage is underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life) and administered by a contracted vision plan administrator. 1 The network 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. Discount programs administered by or arranged through the following independent companies: 1. Discount Vision program MESVisionOptics.com-MESVision 2. LASIK Discount program a. NVison Laser Eye Centers (within California) b. QualSight, Inc. (within California and Nationally) Health plans Supplemental Coverage specialty benefits General PLan Information Benefit Summary Guide 129
Basic life and accidental death and dismemberment (AD&D) insurance plans Blue Shield of California Life & Health Insurance Company (Blue Shield Life) offers simple and cost-effective group term (basic) life and AD&D insurance for small businesses. When you purchase life insurance from Blue Shield Life for your employees, AD&D is included, along with high guaranteed-issue amounts, and you benefit from single-source administration.* Group life and AD&D insurance guidelines Eligible employees 2 to 9 lives Minimum benefit $15,000 Maximum benefit $30,000 Guaranteed issue $30,000 10 to 24 lives Minimum benefit $15,000 Maximum benefit $100,000 Guaranteed issue $100,000 25 to 50 lives Minimum benefit $15,000 Maximum benefit $150,000 Guaranteed issue $150,000 Please note: Subject to additional Blue Shield Life underwriting guidelines. No evidence of insurability is required upon initial eligibility. Basic life insurance Blue Shield Life offers basic life insurance coverage to groups with two or more eligible employees. Flat amounts of coverage from $15,000 up to $150,000 are available (see chart above). Employer groups do not need to purchase medical coverage from Blue Shield in order to purchase life coverage from Blue Shield Life. All employees within the group are eligible for life coverage, even if the group has multiple health carriers. Coverage includes both basic life and AD&D insurance. Dependent life insurance is optional. Benefits include: Standard basic life insurance benefits (for employees and dependents) Waiver of premium provision, for insured employees who are totally disabled before age 60 Accelerated death benefit allows advance payment of death benefits in situations where the employee is terminally ill Individuals may elect to withdraw an accelerated death benefit in $1,000 increments, subject to minimums and maximums Maximum allowed is 50% of benefit or $100,000, whichever is lower Minimum allowed is 10% of benefit or $5,000, whichever is greater If purchased, dependent life coverage includes domestic partner Standard AD&D benefits (for employees only) Full benefit (equal to the life insurance amount) for accidental loss of life Partial benefits for accidental loss of limbs Seat-belt benefit, including an added airbag benefit Special education benefit repatriation benefit Disappearance benefit Felonious assault benefit Exposure benefit Common carrier benefit Surgical reattachment benefit Complete and irrecoverable loss of sight in both eyes benefit Loss of hearing benefit Loss of speech benefit Comatose benefit Minimum coverage amount of $15,000 Benefits are reduced to 65% of the original amount when a subscriber attains the age of 65, and to 50% of the original amount at age 70. All benefits terminate at retirement. Life insurance is underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Group billing for life insurance will be combined with the health plan coverage when applicable. Plan guidelines This is an overview of the basic life and AD&D insurance guidelines. Please refer to the policy for a complete description or contact Life/AD&D Member Services at (888) 800-2742. Only active, full-time (at least 30 hours per week), permanent employees are eligible for coverage. Employees must be enrolled in basic life insurance to be eligible for dependent coverage. If dependent life is chosen, all eligible family members are enrolled at the same coverage and rate. AD&D benefits match basic life benefits. AD&D benefits for all losses resulting from the same accident may not exceed the full amount. Life insurance benefits for children ages 14 days to 6 months are 10% of full benefits. There is no benefit available for children from birth to 14 days. Non-contributory policies: If the employer pays full amount of premium, then all eligible employees must participate. Contributory policies: Minimum 75% participation is required. Employees who do not enroll within 31 days after becoming eligible may need to provide evidence of insurability to be enrolled. * Plans are underwritten by Blue Shield Life and administered by Blue Shield of California. 130 Benefit Summary Guide
General plan information This section provides information you need to know about guaranteed-issue plans, coverage exclusions and limitations, and provider limitations. Please refer to the Evidence of Coverage, Certificate of Insurance, the group policy, or plan contract for a detailed description of coverage benefits and limitations. Guaranteed issue If you employ one to 50 eligible employees and meet the requirements of California s Small Employer Group Act (California Health & Safety Code 1357 et. seq., and Cal Insurance Code 10702 et. seq.), your company is considered a small employer that is eligible for coverage from Blue Shield. This coverage is issued on a guaranteed-issue basis and is guaranteed renewable as described in the plan contract or group policy. Your company must also meet Blue Shield s group eligibility requirements. Check with your Blue Shield representative for additional information on group eligibility criteria. Small businesses can apply for any small business health plan being offered by Blue Shield of California or Blue Shield of California Life & Health Insurance Company at the time of their application for coverage or at the time of their plan contract or policy renewal, consistent with the requirements of the Affordable Care Act (ACA). The group can request a listing(s) of the Blue Shield small business plans available, and applicable rates, from their broker or by contacting Blue Shield directly. Essential Health Benefits All health plans offered in the small business market for plan years beginning on or after January 1, 2014 (both inside and outside of Covered California) will be required to offer a core package of covered services known as Essential Health Benefits (EHB), which must include items and services within at least the following 10 categories: 1. Ambulatory patient services 2. Emergency services 3. Hospitalization 4. Maternity and newborn care 5. Mental health and substance use disorder services, including behavioral health treatment 6. Prescription drugs 7. Rehabilitative and habilitative services and devices 8. Laboratory services 9. Preventive and wellness services and chronic disease management 10. Pediatric services, including oral and vision care No pre-existing condition provisions Blue Shield small business health plans do not contain pre-existing condition provisions. In addition, these Blue Shield plans do not establish rules for eligibility based on health status-related factors, including factors based upon: health status, medical conditions (including physical and mental illness), claims experience, receipt of healthcare services, medical history, genetic information, evidence of insurability (including conditions arising out of acts of domestic violence), or disability. An eligible enrollee is not required to provide a completed health assessment or medical questionnaire as a condition of enrollment in a Blue Shield small business plan. Small business employer standard employee risk rates Along with this Benefit Summary Guide, your Blue Shield representative must provide you with the standard employee risk rates for every Blue Shield plan contract offered to small business employers. Information regarding part-time employee eligibility under SB 1790 (employer option) can be obtained from your Blue Shield representative. Principal exclusions Medical necessity exclusion All services must be medically necessary to be covered. The fact that a physician, hospital, or other provider may prescribe, order, recommend, or approve a service does not, in itself, make it medically necessary, even if the service is not specifically listed as an exclusion or limitation. Blue Shield may limit benefits to the most cost-effective service or exclude benefits for services that are not medically necessary. Additional plan exclusions The first list of exclusions and limitations that appears below applies to all Blue Shield health plans described in this guide. Exclusions specific to the PPO, HSA-HDHP, Full HMO, and Exclusive HMO plans are listed below. For a detailed description of the exclusions and limitations of any health, dental, vision, or other plan, please refer to that plan s Evidence of Coverage and the group contract or the plan s Certificate of Insurance and master group policy. Health plans Supplemental Coverage specialty benefits General PLan Information Benefit Summary Guide 131
All plans Unless specifically covered in the group s health service contract, master group policy, or as an optional benefit, no benefits are provided for (EOC/COI exclusions/limitations): Services not specifically listed in the Evidence of Coverage (EOC) or Certificate of Insurance (COI) Services or procedures that are experimental or investigational in nature, except for services for members who have been accepted into an approved clinical trial for cancer Rest or custodial, maintenance, or domiciliary care to control or change a patient s environment Services performed by house officers, residents, interns, or others in training Services performed by a close relative or by a person who ordinarily resides in the covered person s home Hearing aids, cochlear implants, bone-anchored hearing aids, and auditory brainstem implants 1 Vocational, educational, recreational, art, dance, music, or reading therapy; weight control or exercise programs 2 Services incident to speech therapy, except as specifically listed under speech therapy benefits in the EOC or COI reconstructive surgery and procedures (except as provided for in the EOC or COI) Intersex surgery (except for medically necessary treatment of medical complications); sexual dysfunctions; sexual inadequacies (except for treatment of organically based conditions); artificial insemination; injectables for infertility, GIFT, or in vitro fertilization Infertility services incidental to, or resulting from, procedures for a surrogate mother who is not a plan member eligible for maternity benefits Penile implant devices or surgery, except as medically necessary Routine foot care Learning or behavior problems 2 Testing for intelligence or learning disabilities 2 Organ transplants (except as specifically provided for in the EOC or COI) Cosmetic surgery or any resulting complications, except that medically necessary services to treat complications of cosmetic surgery (e.g., infections or hemorrhages) will be a covered benefit, but only upon review and approval by a Blue Shield physician consultant; no benefits will be provided for reimplantation of breast implants originally provided for cosmetic augmentation Patient convenience items Injury or disease arising out of, or in the course of, any employment for salary, wage, or profit if such injury or disease is covered by any workers compensation law, occupational disease law, or similar legislation Substance abuse treatment, except as specifically provided in the EOC or COI Eyeglasses, contact lenses, or surgery for refractive error (e.g., radial keratotomy) Dental care or services incident to the treatment, prevention, or relief of pain or dysfunction of the temporomandibular joint and/or muscles of mastication, except as specifically provided for in the EOC or COI Dental care and dental supplies, except as specifically provided for in the EOC or COI Orthodontia (except for orthodontic services that are an integral part of reconstructive surgery for cleft palate repair) Orthopedic shoes and non-custom-made or over-thecounter shoe inserts or arch supports, home testing devices, environmental control equipment, exercise equipment, self-help educational devices, and some home monitoring equipment For nonprescription (over-the-counter) medical equipment or supplies that can be purchased without a licensed provider s prescription order, even if a provider writes a prescription order for a nonprescription item, except as specifically provided under home healthcare services, hospice program services, diabetes care, home medical equipment/ prostheses, and other services in the EOC or COI Any service not specifically listed as a covered benefit 1 Cochlear implants, bone-anchored hearing aids, and auditory brainstem implants are excluded for Blue Shield of California Life & Health Insurance Company, but not for Blue Shield of California. 2 This exclusion does not apply to medically necessary services which Blue Shield is required by law to cover for severe mental illnesses or serious emotional disturbances of a child. All plans exclude: Contraceptives and contraceptive devices (except as specifically included in the preventive care, family planning, and infertility services benefit of the EOC or COI) Drugs prescribed in conjunction with treatment on or to the teeth (this exclusion does not apply to antibiotics prescribed to treat infection or to medications prescribed to treat pain) 132 Benefit Summary Guide
PPO and HSA-HDHP plans also exclude: Diagnosis and treatment of causes of infertility Hospitalization primarily for X-ray, laboratory, or diagnostic studies or medical observation Contraceptives and contraceptive devices, except as specifically included in the preventive care, family planning and infertility services benefit of the EOC or COI Prescription drugs from a non-participating pharmacy except in emergency and urgent situations The Full HMO and Exclusive HMO plans also exclude: reversal of a vasectomy or tubal ligation, and repeat vasectomy or tubal ligation Prescription or non-prescription food and nutritional supplements, except as provided for phenylketonuria (PKU)-related formulas as described under the home health care, home hospice, home infusion care benefits, and PKU-related formulas and special food product benefit of the EOC Disposable medical supplies for home use as specified in the exclusions and limitations section of the EOC Physical exams required for licensure, employment, or insurance, unless the exam corresponds to the schedule of routine physical exams as specifically provided for in the EOC Prescription drugs from a non-participating pharmacy, except in emergency and urgent situations Services not provided, prescribed, referred, or authorized by the member s Personal Physician or the Blue Shield HMO, except for emergency or urgent services as described in the EOC * Note: In the Full HMO plans and Exclusive HMO plans, members access mental health and chemical dependency services, other than inpatient services for medical acute detoxification, through the mental health service administrator (MHSA) utilizing MHSA participating providers. Maximum aggregate payment amount PPO and HSA-HDHP plans: There is no lifetime maximum for the aggregate benefits payment amount. Health plans Supplemental Coverage specialty benefits General PLan Information Benefit Summary Guide 133
Si desea recibir este Aviso Sobre Practicas de Privacidad en español, por favor llame a Servicios a Clientes en el numero que se encuentra en su tarjeta de identificación de Blue Shield. Notice of privacy practices Blue Shield of California and Blue Shield of California Life & Health Insurance Company This Notice describes how medical information about you, as a Blue Shield member, may be used and disclosed, and how you can get access to your information. Our privacy commitment At Blue Shield, we understand the importance of keeping your personal information private, and we take our obligation to do so very seriously. In the normal course of doing business, we create records about you, your medical treatment, and the services we provide to you. The information in those records is called protected health information (PHI) and includes your individually identifiable personal information such as your name, address, telephone number, and Social Security number, as well as your health information, such as healthcare diagnosis or claim information. We are required by federal and state law to provide you with this Notice of our legal duties and privacy practices as they relate to your PHI. We are required to maintain the privacy of your PHI and to notify you in the event that you are affected by a breach of unsecured PHI. When we use or give out ( disclose ) your PHI, we are bound by the terms of this Notice, which applies to all records that we create, obtain, and/or maintain that contain your PHI. How we protect your privacy We maintain physical, technical, and administrative safeguards to ensure the privacy of your PHI. To protect your privacy, only Blue Shield workforce members who are authorized and trained are given access to our paper and electronic records and to non-public areas where this information is stored. Workforce members are trained on topics including: Privacy and data protection policies and procedures, including how paper and electronic records are labeled, stored, filed, and accessed. Physical, technical, and administrative safeguards in place to maintain the privacy and security of your PHI. Our corporate Privacy Office monitors how we follow our privacy policies and procedures, and educates our organization on this important topic. How we use and disclose your PHI Uses of PHI without your authorization. We may disclose your PHI without your written authorization if necessary while H0504_13_144F 07162013 S2468_13_144F 07162013 blueshieldca.com 134 Benefit Summary Guide
2 providing health benefits and services to you. We may disclose your PHI for the following purposes: Treatment: To share with nurses, doctors, pharmacists, optometrists, health educators, and other healthcare professionals so they can determine your plan of care. To help you obtain services and treatment you may need for example, ordering lab tests and using the results. To coordinate your health care and related services with a healthcare facility or professional. Payment: To obtain payment of premiums for your coverage. To make coverage determinations for example, to speak to a healthcare professional about payment for services provided to you. To coordinate benefits with other coverage you may have for example, to speak to another health plan or insurer to determine your eligibility or coverage. To obtain payment from a third party that may be responsible for payment, such as a family member. To otherwise determine and fulfill our responsibility to provide your health benefits for example, to administer claims. Healthcare operations: To provide customer service. To support and/or improve the programs or services we offer you. To assist you in managing your health for example, to provide you with information about treatment alternatives you may be entitled to, or to provide you with healthcare service or treatment reminders. To support another health plan, insurer, or healthcare professional who has a relationship with you, to improve the programs it offers you for example, for case management or in support of an accountable care organization (ACO) or patient-centered medical home arrangement. For underwriting, dues, or premium rating, or other activities relating to the creation, renewal, or replacement of a contract for health coverage or insurance. Please note, however, that we will not use or disclose your PHI that is genetic information for underwriting purposes doing so is prohibited by federal law. We may also disclose your PHI without your written authorization for other purposes, as permitted or required by law. This includes: Disclosures to others involved in your health care. If you are present or otherwise available to direct us to do so, we may disclose your PHI to others, for example, a family member, a close friend, or your caregiver. If you are in an emergency situation, are not present, are incapacitated, or if you are deceased, we will use our professional judgment to decide whether disclosing your PHI to others is in your best interest. If we do Confidentiality and Privacy notice of privacy policy Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 135
disclose your PHI in a situation where you are unavailable, we will disclose only information that is directly relevant to the person s involvement with your treatment or for payment related to your treatment. We may also disclose your PHI in order to notify (or assist in notifying) such persons of your location, your general medical condition, or your death. We may disclose your minor child s PHI to the child s other parent. Disclosures to your plan sponsor. We may disclose PHI to the sponsor of your group health plan, which may be your employer, or to a company acting on behalf of the plan sponsor, so that they can monitor, audit, and otherwise administer the health plan you participate in. Your employer is not permitted to use the PHI we disclose for any purpose other than administration of your benefits. See your plan sponsor s plan documents for information about whether your employer/plan sponsor receives PHI, and for a full explanation of the limited uses and disclosures that the plan sponsor may make of your PHI. Disclosures to vendors and accreditation organizations. We may disclose your PHI to: Companies that perform certain services on behalf of Blue Shield. For example, we may engage vendors to help us provide information and guidance to members with chronic conditions like diabetes and asthma. Accreditation organizations such as the National Committee for Quality Assurance (NCQA) for quality measurement purposes. Please note that before we share your PHI, we obtain the vendor s or accreditation organization s written agreement to protect the privacy of your PHI. Communications. We may use your PHI to contact you with information about your Blue Shield health plan coverage, benefits, health-related programs and services, treatment reminders, or treatment alternatives available to you. We do not use your PHI for fundraising purposes. Health or safety. We may disclose your PHI to prevent or lessen a serious and imminent threat to your health or safety, or the health or safety of the general public. Public health activities. We may disclose your PHI to: Report health information to public health authorities authorized by law to receive such information for the purpose of preventing or controlling disease, injury or disability, or monitoring immunizations. Report child abuse or neglect, or adult abuse, including domestic violence, to a government authority authorized by law to receive such reports. Report information about a product or activity that is regulated by the U.S. Food and Drug Administration (FDA) to a person responsible for the quality, safety, or effectiveness of the product or activity. Alert a person who may have been exposed to a communicable disease, if we are authorized by law to give such a notice. Confidentiality and Privacy 3 136 Benefit Summary Guide
4 Health oversight activities. We may disclose your PHI to: A government agency that is legally responsible for oversight of the healthcare system or for ensuring compliance with the rules of government benefit programs such as Medicare or Medicaid. Other regulatory programs that need health information to determine compliance. Research. We may disclose your PHI for research purposes, but only according to, and as allowed by, law. Compliance with the law. We may use and disclose your PHI to comply with the law. Judicial and administrative proceedings. We may disclose your PHI in a judicial or administrative proceeding or in response to a valid legal order. Law enforcement officials. We may disclose your PHI to the police or other law enforcement officials, as required by law or in compliance with a court order or other process authorized by law. Government functions. We may disclose your PHI to various departments of the government, such as the U.S. military or the U.S. Department of State, as required by law. Workers compensation. We may disclose your PHI when necessary to comply with workers compensation laws. Uses of PHI that require your authorization. Other than for the purposes described above, we must obtain your written authorization to use or disclose your PHI. For example, we will not use your PHI for marketing purposes without your prior written authorization, nor will we give your PHI to a prospective employer without your written authorization. Uses and disclosure of certain PHI deemed highly confidential. For certain kinds of PHI, federal and state law may require enhanced privacy protection. This includes PHI that is: Maintained in psychotherapy notes. About alcohol and drug abuse prevention, treatment, and referral. About HIV/AIDS testing, diagnosis, or treatment. About venereal and/or communicable disease(s). About genetic testing. We can only disclose this type of specially protected PHI with your prior written authorization except when specifically permitted or required by law. Authorization cancellation. At any time, you may cancel a written authorization that you previously gave us. When submitted to us in writing, the cancellation will apply to future uses and disclosures of your PHI. It will not affect uses or disclosures made previously, while your authorization was in effect. Your individual rights You have the following rights regarding the PHI that Blue Shield creates, obtains, and/or maintains about you: Right to request restrictions. You may ask us to restrict the way we use and disclose your PHI for treatment, payment, and healthcare operations, as explained in this Notice. We are not required to agree Confidentiality and Privacy notice of privacy policy Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 137
to your restriction requests, but we will consider them carefully. If we agree to a restriction request, we will abide by it until you request or agree to terminate the restriction. We may also inform you that we are terminating our agreement to a restriction. In that case, the termination will apply only to PHI created or received after we have informed you of the termination. Right to receive confidential communications. You may ask to receive Blue Shield communications containing PHI by alternative means or at alternative locations. As required by law, and whenever feasible, we will accommodate reasonable requests. We may require that you make your request in writing. If your request involves a minor child, we may ask you to provide legal documentation to support your request. Right to access your PHI. You may ask to inspect or to receive a copy of certain PHI that we maintain about you in a designated record set. This includes, for example, records of enrollment, payment, claims adjudication, and case or medical management record systems, and any information we used to make decisions about you. Your request must be in writing. Whenever possible, and as required by law, we will provide you with a copy of your PHI in the form (paper or electronic) and format you request. If you request a copy of your PHI, we may charge you a reasonable, cost-based fee for preparing, copying, and/or mailing it to you. In certain limited circumstances permitted by law, we may deny you access to a portion of your records. Right to amend your records. You have the right to ask us to correct or amend the PHI that we maintain about you in a designated record set. Your request must be made in writing and explain why you want your PHI amended. If we determine that the PHI is inaccurate or incomplete, we will correct it if permitted by law. If a doctor or healthcare facility created the PHI that you want to change, you should ask them to amend the information. Right to receive an accounting of disclosures. Upon your written request, we will provide you with a list of the disclosures we have made of your PHI for a specified time period, up to six years prior to the date of your request. However, the list will exclude: Disclosures you have authorized. Disclosures made earlier than six years before the date of your request. Disclosures made for treatment, payment, and healthcare operations purposes, except when required by law. Certain other disclosures that we are allowed by law to exclude from the accounting. If you request an accounting more than once during any 12-month period, we will charge you a reasonable, costbased fee for each accounting report after the first one. Right to name a personal representative. You may name another person to act as your personal representative. Your representative will be allowed access to your PHI, Confidentiality and Privacy 5 138 Benefit Summary Guide
to communicate with the healthcare professionals and facilities providing your care, and to exercise all other HIPAA rights on your behalf. Depending on the authority you grant your representative, he or she may also have authority to make healthcare decisions for you. Right to receive a paper copy of this Notice. Upon your request, we will provide a paper copy of this Notice, even if you have agreed to receive the Notice electronically. See the Notice Availability and Duration section of this Notice. Actions you may take Contact Blue Shield. If you have questions about your privacy rights, believe that we may have violated your privacy rights, or disagree with a decision that we made about access to your PHI, you may contact us: Blue Shield of California Privacy Office P.O. Box 272540 Chico, CA 95927-2540 Phone: Fax: Email: (888) 266-8080 (toll-free) (800) 201-9020 (toll-free) privacy@blueshieldca.com For certain types of requests, you must complete and mail us a form that is available either by calling the customer service number on your Blue Shield member ID card or by visiting our website at blueshieldca.com/bsca/about-blueshield/privacy/home.sp. Contact a government agency. You may also file a written complaint with the Secretary of the U.S. Department of Health & Human Services (HHS) if you believe we may have violated your privacy rights. Your complaint may be sent by email, fax, or mail to the HHS Office for Civil Rights (OCR). For more information, or to file a complaint with the Secretary of HHS, visit the OCR website at www.hhs.gov/ocr/privacy/ hipaa/complaints. If you are a California resident, you may contact the OCR Regional Manager for California as follows: Region IX Regional Manager Office for Civil Rights U.S. Department of Health & Human Services 90 7th St., Suite 4-100 San Francisco, CA 94103 Phone: (800) 368-1019 Fax: (415) 437-8329 TTY: (800) 537-7697 We will not take any action against you if you exercise your right to file a complaint, either with us or with HHS. Notice availability and duration Notice availability. A copy of this Notice is available by calling the customer service number on your Blue Shield member ID card or by visiting our website at blueshieldca.com/bsca/about-blueshield/privacy/confidentiality.sp. Right to change terms of this Notice. We are required to abide by the terms of this Notice as long as it remains in effect. We may change the terms of this Notice at any time, and, at our discretion, we may make the new terms effective for all of your PHI in our possession, including any PHI we created or received before we issued the new Notice. If we change this Notice, we will update the Notice on our website, and if you are enrolled in a Blue Shield benefit plan at that time, we will send you the new Notice when and as required by law. Effective date. This Notice is effective as of August 16, 2013. notice of privacy policy Supplemental Coverage specialty Products General PLan Information Benefit Summary Guide 139
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Contact us Blue Shield sales offices to serve you Northern California San Francisco 50 Beale St. San Francisco, CA 94105 Phone: (415) 229-5272 Fax: (415) 229-6230 Sacramento 4203 Town Center Blvd. El Dorado Hills, CA 95762 Phone: (916) 350-7324 Fax: (916) 350-8609 Fresno 5250 N. Palm Ave., Suite 120 Fresno, CA 93704 Toll-free: (800) 779-1906 Phone: (559) 440-4000 Fax: (559) 436-0371 Walnut Creek 2175 N. California Blvd., Suite 250 Walnut Creek, CA 94596 Toll-free: (877) 685-2676 Phone: (925) 927-7400 Fax: (925) 927-7410 Southern California Los Angeles 100 N. Sepulveda Blvd. El Segundo, CA 90245 Toll-free: (800) 499-3899 Phone: (310) 744-2583 Fax: (310) 744-2680 Costa Mesa 555 Anton Blvd., Suite 800 Costa Mesa, CA 92626 Toll-free: (800) 965-7587 Phone: (714) 428-4800 Fax: (877) 251-2230 San Diego 2275 Rio Bonita Way, Suite 250 San Diego, CA 92108 Toll-free: (877) 847-8851 Phone: (619) 686-4200 Fax: (619) 686-4250 Ontario 3401 Centrelake Drive, Suite 400 Ontario, CA 91761-1205 Toll-free: (800) 628-6501 Phone: (909) 974-5200 Fax: (909) 974-5255 Woodland Hills 6300 Canoga Ave. Woodland Hills, CA 91367 Toll-free: (800) 804-7420 Phone: (818) 598-8000 Fax: (818) 228-5206 An independent member of the Blue Shield Association A16609 (1/14)