benefit summary guide - california health insurance€¦ · health coverage. plus, blue shield...

Effective March 1, 2013

benefit summary guideHealth plan information for individuals and families

With easy access to care from quality provider networks and a choice of 15 health plans that are easy to understand and affordable, Blue Shield is making it easier for you to choose your health coverage. Plus, Blue Shield offers dental, dental + vision*, and life insurance* products to complement your coverage.

Inside this guide, you’ll find detailed benefit charts to help you find the right plan including:

• Arangeofhealthplanoptions

• Achoiceofdental,dental+vision*,andlifeinsurance*plans

This is a summary of plan information and is not a contract. The actual complete terms and conditions of a plan’s benefits and coverage, limitations, and exclusions are located in the Evidence of Coverage and Health Service Agreement (EOC) or Policy for Individuals and Families (Policy). We’ll send you your EOC/Policy if your application for coverage is approved.

Please note: This guide accompanies the Important Legal Information booklet, that explains general plan exclusions and limitations. Please read both documents together.

For questions about the information in this guide, or to obtain a copy of the Important Legal Information booklet, please contact your broker, call us at (888) 256-3650, or visit us online at blueshieldca.com.

Healthcare coverage that fits your needs

* UnderwrittenbyBlueShieldofCaliforniaLife&HealthInsuranceCompany(BlueShieldLife).

BenefitSummaryGuide 1

Health plans

PPO health plans

PPO plans at a glance 2

Benefitsummaries 3

Shield Saver PPO health plans (HSA-eligible, high-deductible health plans)

ShieldSaverPPOplansataglance 36

Benefitsummaries 37

HMO health plans

HMO plans at a glance 43Benefitsummaries 44

Dental, vision, and life insurance products

Dental plans 51

Dental+visionpackage 51

Lifeinsurance 58

Table of contents

2 BenefitSummaryGuide BenefitSummaryGuide 3

PPO plans at a glanceBlueShieldPPOplansoffermemberstheflexibilityand simplicity of having direct access to the physiciansandspecialistsinBlueShieldpreferredprovidernetworkswithouttheneedforareferral.Additionalhighlightsinclude:

• Predictablecopayments,anannualdeductible,and a copayment maximum

• Preventivecareserviceswithoutacopayment withpreferredproviders

• Comprehensive,traditionalPPOplandesigns

• AccesstoqualityprovidernetworksinCalifornia

PPOprovidernetworksMostofthePPOplansofferedbyBlueShieldofCaliforniausetheBlueShieldofCaliforniaprovidernetwork.TheShieldSpectrumPPOSM 5000 plan is offeredbyBlueShieldofCaliforniaLife&HealthInsuranceCompany(BlueShieldLife)andusestheBlueShieldLifeprovidernetwork.Thesesimilarnetworksconsistofpreferredprovidersandpreferredhospitals. Visit blueshieldca.com/findaprovider to see ifyourproviderisinoneofournetworks.

AccesstocareandlimitationsPlan features and copayments vary by plan. MemberswhoreceivecarefromaBlueShieldPPOpreferred provider are responsible for meeting the plan’s calendar-year deductible and coinsurance up to the calendar-year copayment maximum for covered services.

Memberswhoobtaincoveredservicesfromnon-preferred providers are responsible for meeting the calendar-year deductible, the coinsurance up to the non-preferred provider calendar-year copayment/coinsurance maximum, and all charges thatexceedBlueShield’sallowableamount.

PPO health plans


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Shield Secure Plus 2000

Uniform Health Plan Benefits and Coverage Matrix

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Preferred Providers1 Non-preferred Providers1

Calendar Year Medical Deductible (For family coverage, an individual is responsible for satisfying their own individual deductible and that amount accumulates to the family deductible.)

$2,000 per individual / $4,000 per family (all providers combined)

Calendar Year Copayment Maximum(Includes the medical plan deductible. Copayments for Preferred Providers apply to both Preferred and Non-Preferred Provider Calendar Year Copayment Maximum amounts.)

$5,000 per individual / $10,000 per family


Calendar Year Brand Name Drug Deductible $500 per individual Not covered Lifetime Benefit Maximum None

Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1

PROFESSIONAL SERVICESProfessional (Physician) Benefits

Physician and specialist office visits $302,3 50% Other outpatient X-ray, pathology, and laboratory (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities)

30% 50%

CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine (prior authorization is required)

30% 50%4

Preventive Health BenefitsPreventive Health Services (As required by applicable federal and California law)

$02 Not covered

OUTPATIENT SERVICES Outpatient surgery in a hospital 30% 50%5,6

Outpatient surgery performed at an Ambulatory Surgery Center

30% 50%5,7

Outpatient Services for treatment of illness or injury and necessary supplies

30% 50%5,6

Other outpatient X-ray, pathology and laboratory performed in a hospital

30% 50%

Bariatric Surgery (prior authorization required by the Plan; medically necessary surgery for weight loss, for morbid obesity only)8

30% Not covered

CT scans, MRIs, MRAs, PET scans, and cardiac diagnostic procedures utilizing nuclear medicine performed in a hospital (prior authorization is required)

$100 + 30% 50%4

HOSPITALIZATION SERVICES Inpatient Physician Services 30% 50% Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)

30% 50%5,6


30% Not covered

EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission (Copayment does not apply if the member is directly admitted to the hospital for inpatient services)

$100 per visit + 30% $100 per visit + 30%

Emergency room Services resulting in admission (when the member is admitted directly from the ER)

30% 30%

Emergency room Physician Services 30% 30% AMBULANCE SERVICES

Emergency or authorized transport 30% 30%


Covered Services Member Copayments PRESCRIPTION DRUG COVERAGE9,10 Participating Pharmacy Non-Participating

PharmacyRetail prescriptions (up to a 30-day supply)

Formulary Generic Drugs $10 per prescription2,3 Not Covered Formulary Brand Name Drugs $35 per prescription3,11 Not Covered Non-Formulary Brand Name Drugs $60 or 50% (whichever is

greater) per prescription ($150 maximum per

prescription)3,11

Not Covered

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20 per prescription2,3 Not Covered Formulary Brand Name Drugs $70 per prescription3,11 Not Covered Non-Formulary Brand Name Drugs $120 or 50% (whichever is


prescription)3,11

Not Covered

Specialty Pharmacies (up to a 30-day supply) � Specialty Drugs 30% of negotiated rate up to

$150 maximum,3,11Not Covered

Preferred providers1 Non-preferred Providers1

PROSTHETICS/ORTHOTICSProsthetic equipment and devices (Separate office visit copay may apply)

30% 50%

Orthotic equipment and devices (Separate office visit copay may apply)

30% 50%

DURABLE MEDICAL EQUIPMENTOther Durable Medical Equipment 30% 50% Breast Pump $02 Not covered

MENTAL HEALTH SERVICES (PSYCHIATRIC)12

Inpatient Hospital Services 30% 50%5,6

Outpatient visits for severe mental health conditions $302,3 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with Outpatient chemical dependency visits)13

30% Not covered

CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)12

Inpatient Hospital Services for medical acute detoxification

30% 50%5

Outpatient visits (up to 20 visits per Calendar Year combined with Outpatient non-severe mental health Services)13

30% Not covered

HOME HEALTH SERVICESHome health care agency Services (up to 90 prior authorized visits per Calendar Year)

30% Not covered

OTHERPregnancy and Maternity Care Benefits

Prenatal and postnatal Physician office visits 30% 50%5

All necessary Inpatient Hospital Services for normal delivery and Cesarean section

30% 50%5,6

Family Planning Benefits Counseling and consulting14 $02 Not covered Tubal ligation $02 Not covered Vasectomy 30% Not covered Elective abortion 30% Not covered

Rehabilitation Benefits Office location 30% 50%

Chiropractic BenefitsChiropractic Services (up to 12 visits per Calendar Year; visit limit combines Outpatient acupuncture and chiropractic Services)

50%(Blue Shield’s payment is

limited to $25 per visit)

Not covered

Acupuncture BenefitsAcupuncture (up to 12 visits per Calendar Year; visit limit combines Outpatient acupuncture and chiropractic Services)

50%(Blue Shield’s payment is limited to $25 per visit)


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prescription)3,11

Not Covered



prescription)3,11

Not Covered





30% 50%


30% 50%





30% Not covered



30% 50%5


30% Not covered


30% Not covered




30% 50%5,6






Not covered




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

Please Note: Benefits are subject to modification for subsequently enacted state or federal legislation.

Endnotes for Shield Secure Plus 2000

1 Member is responsible for copayment or coinsurance in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of the allowable amounts. Preferred providers accept the Plan’s allowable amounts as payment-in-full forcovered services. Non-preferred providers can charge more than these amounts. When members use non-preferred providers, they must pay the applicable copayment or coinsurance plus any charges that exceed the Plan’s allowable amount. Member is responsible for charges for services by non-preferred and non-participating providers in excess of the allowed amount, even after the copayment/coinsurance maximum is reached. This amount could be substantial. Charges above the allowable amount do not apply toward the medical deductible or copayment/coinsurance maximum.

2 Benefit is available prior to meeting any deductible. 3 These copayments do not apply toward the medical deductible or copayment/coinsurance maximum. They will continue to be

charged once the copayment/coinsurance maximum is reached. See EOC for details. 4 For non-emergency services and supplies received from non-preferred radiology centers, Blue Shield’s payment is limited to $150

per day. Members are responsible for all charges that exceed $150 per day. For non-emergency services and supplies received from non-preferred hospitals, Blue Shield’s payment is limited to $250 per day. Members are responsible for all charges that exceed$250 per day.

5 These copayments do not apply toward the copayment/coinsurance maximum. They will continue to be charged once the copayment/coinsurance maximum is reached. See EOC for details.

6 For non-emergency services and supplies received from a non-preferred hospital or facility, Blue Shield’s payment is limited to $250 per day. Members are responsible for all charges that exceed $250 per day.

7 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatientsurgery services from a hospital, or an ambulatory surgery center affiliated with a hospital with payment according to your healthplan’s hospital services benefits. Blue Shield’s payment is limited to $150 per day. Members are responsible for all charges thatexceed $150 per day.

8 Bariatric surgery is covered when pre-authorized by the Plan. 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 preferred provider and there is no coverage for bariatricservices from non-preferred providers. In addition, if prior authorized by the Plan, a member in a Designated County who is requiredto 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 EOC for further benefit details.

9 This plan’s prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal governmentfor 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 asubsequent 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 Medicare Part D premium.

10 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment and will not be subject to the calendar-year brand-name drug deductible. However, if a brand-name contraceptive is requested when a generic equivalent is available, the member will still be responsible for paying the difference between the cost to the Plan for the brand-name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be covered without a copayment.

11 If a member or physician requests a brand name drug when a generic drug equivalent is available, and the brand name drug deductible has been satisfied, the member is responsible for paying the difference between the Participating Pharmacy contractedrate for the brand name drug and its generic drug equivalent, as well as the applicable generic drug copayment. See EOC for details.

12 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for medical acute detoxification,through a separate network of MHSA participating providers. Inpatient medical acute detoxification is a medical benefit provided by Blue Shield preferred or non-preferred (not MHSA) providers.

13 For MHSA participating providers, the initial visit is treated as if the condition was a severe mental illness or serious emotionaldisturbance of a child. For MHSA non-participating providers, the initial visit is treated as if it were an MHSA participating provider.

14 Includes insertion of IUD, as well as injectable and implantable contraceptives for women.











Calendar Year Brand Name Drug Deductible $500 per individual Not covered

Lifetime Benefit Maximum None




30% 50%


30% 50%4


$02 Not covered



30% 50%5,7


30% 50%5,6


30% 50%


30% Not covered


$100 + 30% 50%4


30% 50%5,6


30% Not covered




30% 30%




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30% 50%


30% 50%4


$02 Not covered



30% 50%5,7


30% 50%5,6


30% 50%


30% Not covered


$100 + 30% 50%4


30% 50%5,6


30% Not covered




30% 30%







prescription)3,11

Not Covered



prescription)3,11

Not Covered





30% 50%


30% 50%





30% Not covered



30% 50%5


30% Not covered


30% Not covered




30% 50%5,6






Not covered









1 Member is responsible for copayment or coinsurance in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of the allowable amounts. Preferred providers accept the Plan’s allowable amounts as payment-in-full forcovered services. Non-preferred providers can charge more than these amounts. When members use non-preferred providers, they must pay the applicable copayment or coinsurance plus any charges that exceed the Plan’s allowable amount. Member is responsible for charges for services by non-preferred and non-participating providers in excess of the allowed amount, even afterthe copayment/coinsurance maximum is reached. This amount could be substantial. Charges above the allowable amount do not apply toward the medical deductible or copayment/coinsurance maximum.









10 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment and will not be subject to the calendar-year brand-name drug deductible. However, if a brand-name contraceptive is requested when a generic equivalent is available, the member will still be responsible for paying the difference between the cost to the Plan for the brand-name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be coveredwithout a copayment.


12 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for medical acute detoxification, through a separate network of MHSA participating providers. Inpatient medical acute detoxification is a medicalbenefit provided by Blue Shield preferred or non-preferred (not MHSA) providers.




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10 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment and will not be subject to the calendar-year brand-name drug deductible. However, if a brand-name contraceptive is requested when a generic equivalent is available, the member will still be responsible for paying the difference between the cost to the Plan for the brand-name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be coveredwithout a copayment.


















30% 50%


30% 50%4


$02 Not covered



30% 50%5,7


30% 50%5,6


30% 50%


30% Not covered


$100 + 30% 50%4


30% 50%5,6


30% Not covered




30% 30%








prescription)3,11

Not Covered



prescription)3,11

Not Covered





30% 50%


30% 50%





30% Not covered



30% 50%5


30% Not covered


30% Not covered




30% 50%5,6






Not covered




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prescription)3,11

Not Covered



prescription)3,11

Not Covered





30% 50%


30% 50%





30% Not covered



30% 50%5


30% Not covered


30% Not covered




30% 50%5,6






Not covered











per day. Members are responsible for all charges that exceed $150 per day. For non-emergency services and supplies received from non-preferred hospitals, Blue Shield’s payment is limited to $250 per day. Members are responsible for all charges that exceed $250 per day.


6 For non-emergency services and supplies received from a non-preferred hospital or facility, Blue Shield’s payment is limited to$250 per day. Members are responsible for all charges that exceed $250 per day.

7 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatient surgery services from a hospital, or an ambulatory surgery center affiliated with a hospital with payment according toyour health plan’s hospital services benefits. Blue Shield’s payment is limited to $150 per day. Members are responsible for allcharges that exceed $150 per day.

8 Bariatric surgery is covered when pre-authorized by the Plan. 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 preferred provider and there is no coverage for bariatricservices from non-preferred providers. In addition, if prior authorized by the Plan, 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 EOC for further benefit details.

9 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 Medicareprescription drug plan, you could be subject to a late enrollment penalty in addition to your Medicare Part D premium.

10 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment and will notbe subject to the calendar-year brand-name drug deductible. However, if a brand-name contraceptive is requested when a generic equivalent is available, the member will still be responsible for paying the difference between the cost to the Plan for the brand-name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be coveredwithout a copayment.






Shield Secure 2000









Calendar Year Brand Name Drug Deductible $3,000 per individual Not covered Lifetime Benefit Maximum None




40% 50%


40% 50%4


$02 Not covered



40% 50%5,7


40% 50%5,6


40% 50%


40% Not covered


$100 + 40% 50%4


40% 50%5,6


40% Not covered




40% 40%




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Shield Secure 2000













40% 50%


40% 50%4


$02 Not covered



40% 50%5,7


40% 50%5,6


40% 50%


40% Not covered


$100 + 40% 50%4


40% 50%5,6


40% Not covered




40% 40%







prescription)3,11

Not Covered



prescription)3,11

Not Covered





40% 50%


40% 50%





40% Not covered



40% 50%5


40% Not covered


40% Not covered




40% 50%5,6






Not covered








Endnotes for Shield Secure 2000

1 Member is responsible for copayment or coinsurance in addition to any charges above allowable amounts. The coinsurance indicatedis a percentage of the allowable amounts. Preferred providers accept the Plan’s allowable amounts as payment-in-full for coveredservices. Non-preferred providers can charge more than these amounts. When members use non-preferred providers, they must pay the applicable copayment or coinsurance plus any charges that exceed the Plan’s allowable amount. Member is responsible for charges for services by non-preferred and non-participating providers in excess of the allowed amount, even after the copayment/coinsurance maximum is reached. This amount could be substantial. Charges above the allowable amount do not apply toward the medical deductible or copayment/coinsurance maximum.


charged once the copayment/coinsurance maximum is reached. See EOC for details. 4 For non-emergency services and supplies received from non-preferred radiology centers, Blue Shield’s payment is limited to $150 per

day. Members are responsible for all charges that exceed $150 per day. For non-emergency services and supplies received from non-preferred hospitals, Blue Shield’s payment is limited to $250 per day. Members are responsible for all charges that exceed $250 per day.




8 Bariatric surgery is covered when pre-authorized by the Plan. 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 arecovered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverageis not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, 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 EOC for further benefit details.

9 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 Medicare Part D plan from October 15th through December 7th of each year. If you do not enroll in a Medicare Part D plan when you are first eligibleto join, you may be subject to a late enrollment penalty in addition to your Part D premium when you enroll at a later date. For more information about your current plan’s prescription drug coverage, call the Customer Service telephone number on your identificationcard, Monday through Thursday between 8:00 a.m. and 5:00 p.m. or on Friday between 9:00 a.m. and 5:00 p.m. The hearing impaired may call the TTY number at (888) 239-6482.



12 Blue Shield has contracted with a specialized health care service plan to act as our mental health services administrator (MHSA). The MHSA provides mental health and chemical dependency services, other than inpatient services for medical acute detoxification, through a separate network of MHSA participating providers. Inpatient medical acute detoxification is a medical benefit provided by Blue Shield preferred or non-preferred (not MHSA) providers.




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charged once the copayment/coinsurance maximum is reached. See EOC for details. 4 For non-emergency services and supplies received from non-preferred radiology centers, Blue Shield’s payment is limited to $150 per





8 Bariatric surgery is covered when pre-authorized by the Plan. 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 arecovered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverageis not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, 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 EOC for further benefit details.

9 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 Medicare Part D plan from October 15th through December 7th of each year. If you do not enroll in a Medicare Part D plan when you are first eligibleto join, you may be subject to a late enrollment penalty in addition to your Part D premium when you enroll at a later date. For more information about your current plan’s prescription drug coverage, call the Customer Service telephone number on your identificationcard, Monday through Thursday between 8:00 a.m. and 5:00 p.m. or on Friday between 9:00 a.m. and 5:00 p.m. The hearing impaired may call the TTY number at (888) 239-6482.






Shield Secure 4000













40% 50%


40% 50%4


$02 Not covered



40% 50%5,7


40% 50%5,6


40% 50%


40% Not covered


$100 + 40% 50%4


40% 50%5,6


40% Not covered




40% 40%








prescription)3,11

Not Covered



prescription)3,11

Not Covered





40% 50%


40% 50%





40% Not covered



40% 50%5


40% Not covered


40% Not covered




40% 50%5,6






Not covered




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prescription)3,11

Not Covered



prescription)3,11

Not Covered





40% 50%


40% 50%





40% Not covered



40% 50%5


40% Not covered


40% Not covered




40% 50%5,6






Not covered









2 Benefit is available prior to meeting any deductible. 3 These copayments do not apply toward the medical deductible or copayment/coinsurance maximum. They will continue to be charged

once the copayment/coinsurance maximum is reached. See EOC for details. 4 For non-emergency services and supplies received from non-preferred radiology centers, Blue Shield’s payment is limited to $150 per




7 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatientsurgery services from a hospital, or an ambulatory surgery center affiliated with a hospital with payment according to your health plan’s hospital services benefits. Blue Shield’s payment is limited to $150 per day. Members are responsible for all charges that exceed $150 per day.

8 Bariatric surgery is covered when pre-authorized by the Plan. 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 arecovered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, 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 EOC for further benefit details.

9 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 Medicare Part D plan from October 15th through December 7th of each year. If you do not enroll in a Medicare Part D plan when you are first eligible to join, you may be subject to a late enrollment penalty in addition to your Part D premium when you enroll at a later date. For more information about your current plan’s prescription drug coverage, call the Customer Service telephone number on your identificationcard, Monday through Thursday between 8:00 a.m. and 5:00 p.m. or on Friday between 9:00 a.m. and 5:00 p.m. The hearing impairedmay call the TTY number at (888) 239-6482.


11 If a member or physician requests a brand name drug when a generic drug equivalent is available, and the brand name drug deductible has been satisfied, the member is responsible for paying the difference between the Participating Pharmacy contracted rate for the brand name drug and its generic drug equivalent, as well as the applicable generic drug copayment. See EOC for details.





Shield Secure 6000













40% 50%


40% 50%4


$02 Not covered



40% 50%5,7


40% 50%5,6


40% 50%


40% Not covered


$100 + 40% 50%4


40% 50%5,6


40% Not covered




40% 40%




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Shield Secure 6000













40% 50%


40% 50%4


$02 Not covered



40% 50%5,7


40% 50%5,6


40% 50%


40% Not covered


$100 + 40% 50%4


40% 50%5,6


40% Not covered




40% 40%







prescription)3,11

Not Covered



prescription)3,11

Not Covered





40% 50%


40% 50%





40% Not covered



40% 50%5


40% Not covered


40% Not covered




40% 50%5,6






Not covered




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Shield Wise 2500












Physician and specialist office visits $25 for first 2 visits per Calendar Year prior to

deductible, then $25 after deductible2,3

50%

Other outpatient X-ray, pathology, and laboratory (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities)

25% 50%


25% 50%4


$02 Not covered



25% 50%4,5,7


25% 50%5,6


25% 50%


25% Not covered


$100 + 25% 50%4


25% 50%5,6


25% Not covered




25% 25%

Emergency room Physician Services 25% 25%



AMBULANCE SERVICES Emergency or authorized transport 25% 25%

PRESCRIPTION DRUG COVERAGE9,10 Participating Pharmacy Non-Participating Pharmacy

Retail prescriptions (up to a 30-day supply) Formulary Generic Drugs $10 per prescription2,3 Not Covered Formulary Brand Name Drugs $35 per prescription3,11 Not Covered Non-Formulary Brand Name Drugs $60 or 50% (whichever is


prescription)3,11

Not Covered



prescription)3,11

Not Covered





25% 50%


25% 50%





25% Not covered



25% 50%5,6


25% Not covered


25% Not covered




25% 50%5,6






Not covered


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prescription)3,11

Not Covered



prescription)3,11

Not Covered





25% 50%


25% 50%





25% Not covered



25% 50%5,6


25% Not covered


25% Not covered




25% 50%5,6






Not covered







Endnotes for Shield Wise 2500


2 Benefit is available prior to meeting any deductible. For physician office visits and outpatient visits for the treatment of severe mental health conditions, each benefit covers two visits per calendar year for a fixed copayment prior to meeting the deductible.

3 These copayments do not apply toward the medical deductible or copayment/coinsurance maximum. They will continue to be chargedonce the copayment/coinsurance maximum is reached. See EOC for details.

4 For non-emergency services and supplies received from non-preferred radiology centers, Blue Shield’s payment is limited to $150 per day. Members are responsible for all charges that exceed $150 per day. For non-emergency services and supplies received from non-preferred hospitals, Blue Shield’s payment is limited to $250 per day. Members are responsible for all charges that exceed $250 per day.












Shield Wise 3500














50%


35% 50%


35% 50%4


$02 Not covered



35% 50%4,5,7


35% 50%5,6


35% 50%


35% Not covered


$100 + 35% 50%4


35% 50%5,6


35% Not covered




35% 35%



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Shield Wise 3500














50%


35% 50%


35% 50%4


$02 Not covered



35% 50%4,5,7


35% 50%5,6


35% 50%


35% Not covered


$100 + 35% 50%4


35% 50%5,6


35% Not covered




35% 35%







prescription)3,11

Not Covered



prescription)3,11

Not Covered





35% 50%


35% 50%





35% Not covered



35% 50%5,6


35% Not covered


35% Not covered




35% 50%5,6






Not covered















7 For non-emergency services and supplies received from non-preferred providers, hospitals, and facilities, Blue Shield’s payment is limited to $150 per day. Members are responsible for all charges that exceed $150 per day.









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7 For non-emergency services and supplies received from non-preferred providers, hospitals, and facilities, Blue Shield’s payment is limited to $150 per day. Members are responsible for all charges that exceed $150 per day.








Shield Wise 4500














50%


45% 50%


45% 50%4


$02 Not covered



45% 50%4,5,7


45% 50%5,6


45% 50%


45% Not covered


$100 + 45% 50%4


45% 50%5,6


45% Not covered




45% 45%








prescription)3,11

Not Covered



prescription)3,11

Not Covered





45% 50%


45% 50%





45% Not covered



45% 50%5,6


45% Not covered


45% Not covered




45% 50%5,6






Not covered


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prescription)3,11

Not Covered



prescription)3,11

Not Covered





45% 50%


45% 50%





45% Not covered



45% 50%5,6


45% Not covered


45% Not covered




45% 50%5,6






Not covered

Covered Services Member Copayments Acupuncture Benefits

Acupuncture (up to 12 visits per Calendar Year; visit limit combines Outpatient acupuncture and chiropractic Services)





















Shield Spectrum PPO 5000

Underwritten by Blue Shield of California Life & Health Insurance Company.


THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.










Physician and specialist office visits $35 50% Other outpatient X-ray, pathology, and laboratory (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities)

30% 50%


30% 50%


$02 Not covered



30% 50%3,5


30% 50%3,4


30% 50%


30% 50%3,4


30% 50%


30% 50%3,4


30% 50%3,4

EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission 30% 30% Emergency room Services resulting in admission 30% 30% Emergency room Physician Services 30% 30%



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Underwritten by Blue Shield of California Life & Health Insurance Company.


THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.










Physician and specialist office visits $35 50% Other outpatient X-ray, pathology, and laboratory (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities)

30% 50%


30% 50%


$02 Not covered



30% 50%3,5


30% 50%3,4


30% 50%


30% 50%3,4


30% 50%


30% 50%3,4


30% 50%3,4

EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission 30% 30% Emergency room Services resulting in admission 30% 30% Emergency room Physician Services 30% 30%





greater) per prescription9,10Not Covered


greater) per prescription9,10Not Covered

Specialty Pharmacies (up to a 30-day supply) � Home Self-Administered Injectables 30% of negotiated rate9,10 Not Covered Preferred providers1 Non-preferred Providers1


30% 50%


30% 50%




Outpatient visits for severe mental health conditions $35 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)12

30% Not covered

CHEMICAL DEPENDENCY SERVICES11 (SUBSTANCE ABUSE)Inpatient Hospital Services for medical acute detoxification

30% 50%3,4

Outpatient visits (up to 20 visits per Calendar Year combined with outpatient non-severe mental health visits)12

30% Not covered


30% Not covered


Prenatal and postnatal Physician office visits 30% 50% All necessary Inpatient Hospital Services for normal delivery and Cesarean section

30% 50%3,4



Chiropractic BenefitsChiropractic Services Not covered Not covered

Acupuncture BenefitsAcupuncture Not covered Not covered





Endnotes for Shield Spectrum PPO 5000

1 Member is responsible for copayment or coinsurance in addition to any charges above allowable amounts. The coinsurance indicatedis a percentage of the allowable amounts. Preferred providers accept the Plan’s allowable amounts as payment-in-full for coveredservices. Non-preferred providers can charge more than these amounts. When members use non-preferred providers, they must pay the applicable copayment or coinsurance plus any charges that exceed the Plan’s allowable amount. Charges above the allowable amount do not apply toward the medical deductible or copayment/coinsurance maximum.

2 Benefit is available prior to meeting any deductible. 3 These copayments do not apply toward the copayment/coinsurance maximum. They will continue to be charged once the

copayment/coinsurance maximum is reached. See Policy for details. 4 For non-emergency hospital services and supplies received from a non-preferred hospital, Blue Shield’s payment is limited to $250 per

day. Members are responsible for all charges that exceed $250 per day. 5 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatient

surgery services from a hospital, or an ambulatory surgery center affiliated with a hospital with payment according to your health plan’s hospital services benefits. Blue Shield’s payment is limited to $150 per day. Members are responsible for all charges that exceed $150 per day.

6 Bariatric surgery is covered when pre-authorized by the Plan. 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 arecovered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, 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 Policy for further benefit details.

7 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 Medicare Part D premium.


9 These copayments do not apply toward the medical deductible or copayment/coinsurance maximum. They will continue to be chargedonce the copayment/coinsurance maximum is reached. See Policy for details.

10 If a member or physician requests a brand name drug when a generic drug equivalent is available, and the brand name drug deductible has been satisfied, the member is responsible for paying the difference between the Participating Pharmacy contracted rate for the brand name drug and its generic drug equivalent, as well as the applicable generic drug copayment. See Policy for details.





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2 Benefit is available prior to meeting any deductible. 3 These copayments do not apply toward the copayment/coinsurance maximum. They will continue to be charged once the

copayment/coinsurance maximum is reached. See Policy for details. 4 For non-emergency hospital services and supplies received from a non-preferred hospital, Blue Shield’s payment is limited to $250 per



6 Bariatric surgery is covered when pre-authorized by the Plan. 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 arecovered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, 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 Policy for further benefit details.



9 These copayments do not apply toward the medical deductible or copayment/coinsurance maximum. They will continue to be chargedonce the copayment/coinsurance maximum is reached. See Policy for details.

10 If a member or physician requests a brand name drug when a generic drug equivalent is available, and the brand name drug deductible has been satisfied, the member is responsible for paying the difference between the Participating Pharmacy contracted rate for the brand name drug and its generic drug equivalent, as well as the applicable generic drug copayment. See Policy for details.

















Physician and specialist office visits 35%2 50% Other outpatient X-ray, pathology, and laboratory (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities)

35% 50%


35% 50%

Preventive Health Benefits Preventive Health Services As required by applicable federal and California law

$03

Not covered OUTPATIENT SERVICES

Outpatient surgery in a hospital 35% 50%2,4


35% 50%2,5


35% 50%2,4


35% 50%


35% 50%2,4


35% 50%

HOSPITALIZATION SERVICES Inpatient Physician Services 35% 50% Inpatient Non-emergency Facility Services (Semi-private room and board, and medically necessary Services and supplies, including Subacute Care)

35% 50%2,4


35% 50%2,4

EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission $100 per visit + 35% $100 per visit + 35% Emergency room Services resulting in admission 35% 35%






Formulary Generic Drugs $10 per prescription3,9 Not Covered Formulary Brand Name Drugs $45 per prescription9,10 Not Covered Non-Formulary Brand Name Drugs $60 or 50%, whichever is

greater (Maximum copayment of $150 per

prescription)9,10

Not Covered

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20 per prescription3,9 Not Covered Formulary Brand Name Drugs $90 per prescription9,10 Not Covered Non-Formulary Brand Name Drugs $120 or 50%, whichever is


prescription)9,10

Not Covered

Specialty Pharmacies (up to a 30-day supply) � Home Self-Administered Injectables 35% of negotiated rate9,10 Not Covered



35% 50%


35% 50%



Inpatient hospital Services 35% 50%2,4

Outpatient visits for severe mental health conditions 35%2 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)12

35% Not covered

CHEMICAL DEPENDENCY SERVICES11 (SUBSTANCE ABUSE) Inpatient Hospital Services for medical acute detoxification

35% 50%2,4


35% Not covered


35% Not covered



35% 50%2,4


Rehabilitation Services Office location 35% 50%


Acupuncture Benefits Acupuncture Not covered Not covered





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Formulary Generic Drugs $10 per prescription3,9 Not Covered Formulary Brand Name Drugs $45 per prescription9,10 Not Covered Non-Formulary Brand Name Drugs $60 or 50%, whichever is


prescription)9,10

Not Covered

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20 per prescription3,9 Not Covered Formulary Brand Name Drugs $90 per prescription9,10 Not Covered Non-Formulary Brand Name Drugs $120 or 50%, whichever is


prescription)9,10

Not Covered

Specialty Pharmacies (up to a 30-day supply) � Home Self-Administered Injectables 35% of negotiated rate9,10 Not Covered



35% 50%


35% 50%



Inpatient hospital Services 35% 50%2,4

Outpatient visits for severe mental health conditions 35%2 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)12

35% Not covered

CHEMICAL DEPENDENCY SERVICES11 (SUBSTANCE ABUSE) Inpatient Hospital Services for medical acute detoxification

35% 50%2,4


35% Not covered


35% Not covered



35% 50%2,4


Rehabilitation Services Office location 35% 50%


Acupuncture Benefits Acupuncture Not covered Not covered






2 These copayments do not apply toward the copayment/coinsurance maximum. They will continue to be charged once the copayment/coinsurance maximum is reached. See the EOC for details.

3 Benefit is available prior to meeting any deductible. 4 For non-emergency hospital services and supplies received from a non-preferred hospital, Blue Shield’s payment is limited to $250 per



6 Bariatric surgery is covered when pre-authorized by the Plan. 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 arecovered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, 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 Evidence of Coverage for further benefit details.



9 These copayments do not apply toward the medical deductible or copayment/coinsurance maximum. They will continue to be chargedonce the copayment/coinsurance maximum is reached. See the EOC for details.






ShieldSaverPPOplansataglanceShieldSaverplansarehigh-deductiblehealthplansthatmeetcurrenthealthsavingsaccount(HSA)eligibility requirements.

Additionalhighlightsinclude:

• Preventivecareserviceswithoutacopaymentbefore meeting the annual deductible

• CompatibilitywithanHSA,soyoucanenjoy potential tax savings

• 100%coverageforallcoveredin-networkservicesafter meeting the out-of-pocket maximum

• Lowout-of-pocketmaximumsforcoveredservices

PPOprovidernetworksShieldSaverplansareunderwrittenbyBlueShieldofCaliforniaandutilizetheBlueShieldofCaliforniapreferredprovidernetwork.Visitblueshieldca.com/findaprovidertoseeifyourproviderisinournetwork.

AccesstocareandlimitationsMemberswhoreceivecarefromaBlueShieldPPOpreferred provider are responsible for meeting their plan’s calendar-year deductible and all charges thatexceedBlueShield’sallowableamountforcoveredservices.Memberswhoreceivecarefromnon-preferred providers are responsible for meeting their plan’s non-preferred provider calendar-year deductible, non-preferred provider calendar-year out-of-pocket maximum, and all charges that exceed BlueShield’sallowableamountforcoveredservices.

Note:AlthoughmostconsumerswhoenrollinanHSA-compatiblehealthplanareeligibletoopenanHSA,youshouldconsultwithafinancialadvisertodetermineifanHSA/HDHPisagoodfinancialfitforyou.BlueShielddoesnotoffertaxadviceorHSAs.HSAsareofferedthroughfinancialinstitutions.formoreinformationaboutHSAs,eligibility,andthelaw’scurrent provisions, ask your financial or tax adviser.

ShieldSaverHSA-eligible,high-deductible health plans (HDHPs)


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Shield Saver 4000 (HSA-Compatible)






$4,000 per individual / $8,000 per family (excludes Preferred Provider deductible)

Calendar Year Out-of-Pocket Maximum(Includes the medical plan deductible)



(excludes Preferred Provider Out-of-Pocket Copayment Maximum)




Physician and specialist office visits $0 after deductible 50% Other outpatient X-ray, pathology, and laboratory (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities)

$0 after deductible 50%


$0 after deductible 50%2


$03 Not covered

OUTPATIENT SERVICES Outpatient surgery in a hospital $0 after deductible 50%4


$0 after deductible 50%2,5






$0 after deductible Not covered



HOSPITALIZATION SERVICES Inpatient Physician Services $0 after deductible 50% Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)




EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission $0 after deductible $0 after deductible Emergency room Services resulting in admission (when the member is admitted directly from the ER)

$0 after deductible $0 after deductible

Emergency room Physician Services $0 after deductible $0 after deductible AMBULANCE SERVICES

Emergency or authorized transport $0 after deductible $0 after deductible




Formulary Generic Drugs $0 after deductible Not Covered Formulary Brand Name Drugs $0 after deductible9 Not Covered Non-Formulary Brand Name Drugs $0 after deductible9 Not Covered

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $0 after deductible Not Covered Formulary Brand Name Drugs $0 after deductible9 Not Covered Non-Formulary Brand Name Drugs $0 after deductible9 Not Covered

Specialty Pharmacies (up to a 30-day supply) � Specialty Drugs $0 after deductible9 Not Covered Preferred providers1 Non-preferred Providers1





DURABLE MEDICAL EQUIPMENTOther Durable Medical Equipment $0 after deductible 50% Breast Pump $03 Not covered


Inpatient Hospital Services $0 after deductible 50%4

Outpatient visits for severe mental health conditions $0 after deductible 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with Outpatient chemical dependency visits)11










Prenatal and postnatal Physician office visits $0 after deductible 50% All necessary Inpatient Hospital Services for normal delivery and Cesarean section


Family Planning Benefits Counseling and consulting12 $03 Not covered Tubal ligation $03 Not covered Vasectomy $0 after deductible Not covered Elective abortion $0 after deductible Not covered

Rehabilitation Benefits Office location $0 after deductible 50%


$0 after deductible (Blue Shield’s payment is


Not covered


$0 after deductible (Blue Shield’s payment is limited to $25 per visit)





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Not covered






Endnotes for Shield Saver 4000

1 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield’s allowable amounts as full payment for covered services. Non-preferred providers can charge more than these amounts. When members use non-preferred providers, they must pay the applicable copayment plus any amount that exceed Blue Shield’s allowable amount. Member is responsible for charges for services by non-preferred andnon-participating providers in excess of the allowed amount, even after the copayment/coinsurance maximum is reached. This amountcould be substantial. Charges in excess of the allowable amount do not apply toward the medical deductible or out-of-pocket maximum. Payments applied to your medical deductible apply towards the out-of-pocket maximum.


3 Benefit is available prior to meeting any deductible. 4 For non-emergency services and supplies received from a non-preferred hospital or facility, Blue Shield’s payment is limited to $300

per day. Members are responsible for all charges that exceed $300 per day. 5 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatient




8 Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment and will not be subject to the calendar-year deductible. However, if a brand-name contraceptive is requested when a generic equivalent is available,the member will still be responsible for paying the difference between the cost to the Plan for the brand-name contraceptive and its generic drug equivalent. In addition, select contraceptives may need prior authorization to be covered without a copayment.

9 If a member or physician requests a brand name drug when a generic drug equivalent is available, the member is responsible forpaying the difference between the Participating Pharmacy contracted rate for the brand name drug and its generic drug equivalent, as well as the applicable generic drug copayment. The difference in cost will not apply to the medical deductible or out-of-pocketmaximum.











$6,000 per individual / $12,000 per family (excludes

Preferred Provider deductible)













$03 Not covered




Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under “Rehabilitation benefits”)

















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$6,000 per individual / $12,000 per family (excludes

Preferred Provider deductible)













$03 Not covered




Outpatient Services for treatment of illness or injury and necessary supplies (Except as described under “Rehabilitation benefits”)













































Not covered







HMO plans at a glanceAccess+HMO plansofferawiderangeofbenefitsincluding:

• Lowcopaymentsforofficevisitsandprescriptiondrugs

• DirectaccesstospecialistswithinyourPersonalPhysician’smedicalgroupwithoutareferral*

• Practicallynoclaimforms

* TousetheAccess+SpecialistSM option for services other than mental health or chemical dependency, your Personal Physician must belong to a medical grouporIPAthathasdecidedtobecomeanAccess+providergroup. Access+Specialist visits for mental health services for other than severe mental illnesses or serious emotional disturbances of a child, and for chemicaldependencycare,willaccruetowardthe20-visit-per-calendar- yearmaximum.Inaddition,allAccess+Specialist visits require a copayment pervisit.MentalhealthandchemicaldependencyAccess+Specialist visits areaccessedthroughtheBlueShieldmentalhealthserviceadministrator(MHSA)utilizingMHSAparticipatingproviders.

HMO health plans

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Access+ Value HMO SM





Calendar Year Copayment Maximum (Includes the medical plan deductible)


Calendar Year Brand Name Drug Deductible $400 Lifetime Benefit Maximum None

Plan services and supplies are covered when performed, prescribed or authorized by your Personal Physician. Limitations and exclusions apply for certain services that are not obtained from or approved by your Personal Physician. See the EOC for details.

Covered Services1 Member Copayments PROFESSIONAL SERVICES Professional (Physician) Benefits � Physician and specialist office visits $35 per visit2,3

� Outpatient X-ray, pathology and laboratory $352,3

Access+ Specialist Benefits � Office visit, Examination or Other Consultation

(Self-referred office visits and consultations only)$50 per visit2,4,5

Preventive Health Benefits � Preventive Health Services

(As required by applicable federal and California law)$02

OUTPATIENT SERVICES � Outpatient surgery in a hospital 40% per visit � Outpatient surgery performed at an Ambulatory

Surgery Center6$150 per visit

� Outpatient Services for treatment of illness or injury and necessary supplies

40% per visit2,3

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) � Inpatient Physician Services $35 per visit2,3

� Inpatient Non-emergency Facility Services �

40% per admit

EMERGENCY HEALTH COVERAGE � Emergency room Services not resulting in admission

(Copayment does not apply if the member is directly admitted to the hospital for inpatient services)

$150 per visit2,3

� Emergency room Physician Services $35 per visit2,3

AMBULANCE SERVICES � Emergency or authorized transport $50 per trip2,3

PRESCRIPTION DRUG COVERAGE7,8,9,10 Participating PharmacyRetail Prescriptions (up to a 30-day supply)� Formulary Generic Drugs $10/prescription2,4

� Formulary Brand Name Drugs $35/prescription4,11

Mail Service Prescriptions (up to a 60-day supply)� Formulary Generic Drugs $20/prescription2,4


Specialty Pharmacies (up to a 30-day supply)� Home Self-Administered Injectables 20% of negotiated rate up to $100 maximum4,11


50%2,4

Orthotic equipment and devices(Separate office visit copay may apply)

50%2,4


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Access+ Value HMO SM









Covered Services1 Member Copayments PROFESSIONAL SERVICES Professional (Physician) Benefits � Physician and specialist office visits $35 per visit2,3

� Outpatient X-ray, pathology and laboratory $352,3

Access+ Specialist Benefits � Office visit, Examination or Other Consultation

(Self-referred office visits and consultations only)$50 per visit2,4,5

Preventive Health Benefits � Preventive Health Services

(As required by applicable federal and California law)$02

OUTPATIENT SERVICES � Outpatient surgery in a hospital 40% per visit � Outpatient surgery performed at an Ambulatory

Surgery Center6$150 per visit

� Outpatient Services for treatment of illness or injury and necessary supplies

40% per visit2,3

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services) � Inpatient Physician Services $35 per visit2,3

� Inpatient Non-emergency Facility Services �

40% per admit

EMERGENCY HEALTH COVERAGE � Emergency room Services not resulting in admission

(Copayment does not apply if the member is directly admitted to the hospital for inpatient services)

$150 per visit2,3

� Emergency room Physician Services $35 per visit2,3

AMBULANCE SERVICES � Emergency or authorized transport $50 per trip2,3

PRESCRIPTION DRUG COVERAGE7,8,9,10 Participating PharmacyRetail Prescriptions (up to a 30-day supply)� Formulary Generic Drugs $10/prescription2,4


Mail Service Prescriptions (up to a 60-day supply)� Formulary Generic Drugs $20/prescription2,4


Specialty Pharmacies (up to a 30-day supply)� Home Self-Administered Injectables 20% of negotiated rate up to $100 maximum4,11


50%2,4

Orthotic equipment and devices(Separate office visit copay may apply)

50%2,4

Covered Services1 Member Copayments DURABLE MEDICAL EQUIPMENT� Other Durable Medical Equipment

(member share is based upon allowed charges)50%2,4

� Breast Pump $02


� Inpatient Hospital Services 40% per admit � Outpatient visits for severe mental health conditions $353 per visit ($504 per visit if provider is MHSA Access+

Specialist provider)2,5

� Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)13

$35 per visit ($50 per visit if provider is MHSA Access+ Specialist provider)2,4,5


� Inpatient Hospital Services for medical acute detoxification

40% per admit

� Outpatient visits (up to 20 visits per Calendar Year combined with outpatient non-severe mental health visits)13

$35 per visit ($50 per visit if provider is MHSA Access+ Specialist provider)2,4,5

HOME HEALTH SERVICES� Home health care agency Services $352,3

OTHERPregnancy and Maternity Care Benefits14

� Prenatal and postnatal Physician office visits $35 per visit2,3

� All necessary Inpatient Hospital Services for normal delivery, Cesarean section, and complications of pregnancy

40% per admit

Family Planning Benefits � Counseling and consulting15 $0 per visit2,3

� Infertility Services Not covered � Tubal ligation $0 per occurrence2,3

� Elective abortion $100 per occurrence2,3

� Vasectomy $75 per occurrence2,3

Rehabilitation Benefits � Office location $35 per visit2,3

Chiropractic BenefitsChiropractic Services Not covered

Urgent Care Benefits (BlueCard® Program)16

� Urgent Services outside your Personal Physician Service Area

$50 per visit2



Endnotes for Access+ Value HMO

1 Benefits are provided only for services that are medically necessary, as determined by the Personal Physician or Access+ ValueHMO except in an emergency or as otherwise specified, and must be received while the patient is a current member.

2 Benefit is available prior to meeting any deductible. 3 These copayments do not apply toward the medical deductible, but do apply toward the copayment/coinsurance maximum, and will

not be charged once the copayment/coinsurance maximum is reached. See the EOC for details. 4 These copayments do not apply toward the medical deductible or copayment/coinsurance maximum. They will continue to be

charged once the copayment/coinsurance maximum is reached. See the EOC for details. 5 To use the Access+ Specialist option for other than mental health or chemical dependency services, your Personal Physician must

belong to a medical group or IPA that has decided to become an Access+ Provider Group. Access+ Specialist visits for mental health services for other than severe mental illnesses or serious emotional disturbances of a child, and for chemical dependencycare will apply towards the 20-visit-per-calendar-year maximum. In addition, all Access+ Specialist visits require a copayment per visit. Mental health and chemical dependency Access+ Specialist visits are accessed through the MHSA utilizing MHSA participating providers.

6 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatientsurgery services from a hospital, or an ambulatory surgery center affiliated with a hospital with payment according to your healthplan’s hospital services benefits.


8 Only medically necessary outpatient formulary drugs are covered, unless prior authorization is obtained from Blue Shield Pharmacy Services. Non-formulary drugs may be covered only if prior authorization is obtained from Blue Shield Pharmacy Services. After allnecessary documentation is available from your Physician, prior authorization approval or denial will be provided to your Physicianwithin 5 business days or within 72 hours for an expedited review. If approved, member is then responsible for the brand prescriptioncopayment. Please see the EOC for details.

9 Drugs obtained at a Non-Participating Pharmacy are not covered, unless Medically Necessary for a covered emergency, includingDrugs for emergency contraception.



12 Blue Shield of California has contracted with a specialized health care service plan to act as the plan’s mental health servicesadministrator (MHSA) and to provide mental health and chemical dependency services, other than inpatient services for medical acute detoxification, through a separate network of MHSA participating providers. Inpatient services for medical acute detoxificationare accessed through Blue Shield utilizing HMO network (not MHSA) providers. For all other mental health and chemical dependency services, members should access MHSA participating providers.


14 Except for the treatment of involuntary complications of pregnancy, pregnancy/maternity benefits for a pregnancy that qualifies as a Waivered Condition are not available during the six-month period beginning as of the effective date of coverage. See the EOC fordetails.

15 Includes insertion of IUD, as well as injectable and implantable contraceptives for women. 16 Authorization by Blue Shield is required for more than two out-of-area follow-up outpatient visits or for out-of-area follow-up care that

involves a surgical or other procedure or inpatient stay. After all necessary documentation is available from your Physician, prior authorization approval or denial will be provided to your Physician within two working days of the request.


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Endnotes for Access+ Value HMO

1 Benefits are provided only for services that are medically necessary, as determined by the Personal Physician or Access+ ValueHMO except in an emergency or as otherwise specified, and must be received while the patient is a current member.
















Access+ HMO package



Medical Benefits







Covered Services1 Member Copayments PROFESSIONAL SERVICES Professional (Physician) Benefits

Physician and specialist office visits $20 per visit2,3

Outpatient X-ray, pathology and laboratory $202,3

Access+ Specialist BenefitsOffice visit, Examination or Other Consultation (Self-referred office visits and consultations only)

$35 per visit2,4.,5

Preventive Health Benefits Preventive Health Services (As required by applicable federal and California law)

$02

OUTPATIENT SERVICES Outpatient surgery in a hospital $250 per visit Outpatient surgery performed at an Ambulatory Surgery Center6

$150 per visit


$35 per visit2,3

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services)

Inpatient Physician Services $20 per visit2,3

Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)

$250 per admit


$75 per visit2,3

Emergency room Physician Services $20 per visit2,3

AMBULANCE SERVICES Emergency or authorized transport $50 per trip2,3

PRESCRIPTION DRUG COVERAGE7,8,9,10 Participating PharmacyRetail Prescriptions (up to a 30-day supply)

Generic drugs $10 per prescription2,4

Formulary brand-name drugs $35 per prescription4,11

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20/prescription2,4

Formulary Brand Name Drugs $70/prescription4,11

Specialty Pharmacies (up to a 30-day supply)Home Self-Administered Injectables 20% of negotiated rate up to $100 maximum4,11


Covered Services1 Member Copayments PROSTHETICS/ORTHOTICS

Prosthetic equipment and devices (Separate office visit copay may apply)

50%2,4


50%2,4

DURABLE MEDICAL EQUIPMENTOther Durable Medical Equipment (member share is based upon allowed charges)

50%2,4

Breast Pump $02


Inpatient Hospital Services $250 per admit Outpatient visits for severe mental health conditions $203 per visit ($354 per visit if provider is

MHSA Access+ Specialist provider)2,5

Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)13

$20 per visit($35 per visit if provider is

MHSA Access+ Specialist provider)2,4,5



$250 per admit


$20 per visit ($35 per visit if provider is


HOME HEALTH SERVICESHome health care agency Services $202,3


Prenatal and postnatal Physician office visits $20 per visit2,3

All necessary Inpatient Hospital Services for normal delivery, Cesarean section, and complications of pregnancy

$250 per admit

Family Planning Counseling and consulting15 $0 per visit2,3

Infertility Services Not covered Tubal ligation $0 per occurrence2,3

Elective abortion $100 per occurrence2,3

Vasectomy $75 per occurrence2,3

Rehabilitation Benefits Office location $20 per visit2,3




$50 per visit2



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Covered Services1 Member Copayments PROSTHETICS/ORTHOTICS

Prosthetic equipment and devices (Separate office visit copay may apply)

50%2,4


50%2,4

DURABLE MEDICAL EQUIPMENTOther Durable Medical Equipment (member share is based upon allowed charges)

50%2,4

Breast Pump $02


Inpatient Hospital Services $250 per admit Outpatient visits for severe mental health conditions $203 per visit ($354 per visit if provider is

MHSA Access+ Specialist provider)2,5

Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)13

$20 per visit($35 per visit if provider is




$250 per admit


$20 per visit ($35 per visit if provider is


HOME HEALTH SERVICESHome health care agency Services $202,3


Prenatal and postnatal Physician office visits $20 per visit2,3

All necessary Inpatient Hospital Services for normal delivery, Cesarean section, and complications of pregnancy

$250 per admit

Family Planning Counseling and consulting15 $0 per visit2,3

Infertility Services Not covered Tubal ligation $0 per occurrence2,3

Elective abortion $100 per occurrence2,3

Vasectomy $75 per occurrence2,3

Rehabilitation Benefits Office location $20 per visit2,3




$50 per visit2


Endnotes for Access+ HMO package

1 Benefits are provided only for services that are medically necessary, as determined by the Personal Physician or Access+ HMO except in an emergency or as otherwise specified, and must be received while the patient is a current member.










11 If a member or physician requests a brand name drug when a generic drug equivalent is available, and the brand name drug deductible has been satisfied, the member is responsible for paying the difference between the Participating Pharmacy contractedrate for the brand name drug and its generic drug equivalent, as well as the applicable generic drug copayment. See EOC for details







Blue Shield of California Individual and Family Dental HMO Plan

Benefit summary

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND HEALTH SERVICES AGREEMENT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Using your dental HMO planWith our dental HMO plan, you'll have access to an extensive network of dental providers without paying deductibles or filling outclaim forms. Plus, it's easy. First, choose a dental provider from our network during enrollment. Then, contact this dental providerfor your dental care. If you have questions or want to switch providers, call Customer Service at (800) 585-8111.

In-Network Calendar Year Deductible $0Annual Benefit Maximum Not Applicable

Covered Services Member Pays

Diagnostic and Preventive Services (includes routine oral exams, cleaning, diagnostic casts, and X-rays)

$20 per visit copayment

Full mouth x-rays1 $10 in addition to $20 per visit copayment

Sealants2, 3 $10 per tooth in addition to $20 per visit copayment

Space maintainers2 $40 or billed charged whichever is less for lab fees in addition to $20 per visit copayment

Basic Services (includes anesthesia and restorative destistry) 80% of the Access+ Dentist’s Billed Charges

Major Services (includes cast restorations, endodontics, oral surgery, and periodontics) 80% of the Access+ Dentist’s Billed Charges

Additional Services (includes palliative treatment, applicaiton of desensitizing medication, occlusal guards by report; occlusal adjustment; consultation (diagnostic service provided by dentist or physician other than practitioner roviding treatment), and hospital calls)

80% of the Access+ Dentist’s Billed Charges

Emergency Services

Using Access+ Dentist network Member copayments for Services are as shown above

Using non Access+ Dentist 100% of charge, max $50 per occurrence

Using Out-of-State No coverage

1 Limited to one series in any period of 36 consecutive months.

2 Limited to Members under age 16.

3 One treatment to permanent molars only in any period of 60 consecutive months. Maximum of 4 teeth per lifetime

Many benefits have pre-determined annual schedules and frequency limitations based on last delivery date and dental necessity. If you are unsure about the frequency of when a benefit can be accessed, you can call (888) 702-4171.This is only a summary of the Blue Shield Access+ HMO® Dental Plan. For exact terms and conditions of coverage, including exclusions and limitations, please refer to the Evidence of Coverage and Health Services Agreement.

Access+ HMO® Dental Plan (Dental plan included in the Access+ HMO Plan Package)


Dental,dental+vision,andindividualterm life insurance coverage

Dental PPO plan benefits

• Accesstoover21,000generalcareandspecialtydentist locations in California.3

• Awiderangeofdentalbenefits,includingmostdiagnostic and preventive services and oral cancerscreening,atnoadditionalcostwhenusingadentalnetworkprovider.

• Coverageevenwhenyouuseanon-networkdentist. The plan reimburses members up to anallowedamountforcoveredservices,andmembers pay the remaining balance of the total billed charges.

• nowaitingperiodfordiagnosticorpreventiveservices(three-monthwaitingperiodforminorservices;12-monthwaitingperiodformajor restorative and orthodontic services).

• Affordablecopaymentsforbothbasicand majorservices.

SpecialtyDuodental+visionpackage

• SpecialtyDuooffersdentalandvisionprotection.The dental benefits are identical to the dental PPO plan above.

• Accesstomorethan6,000contractedvisioncareprovider locations in California,3 including retail chainsopenoneveningsandweekends.

ValueSmileSM PPO2

• Accesstoover21,000generalcareandspecialtydentist locations in California.3

• nochargeforpreventiveanddiagnosticplanservices, including oral cancer screening, whenusingnetworkproviders.

• nowaitingperiodsfordiagnosticor preventive services.

Dental HMO plan benefits

• Accesstoover9,000dentalproviderlocationsinCalifornia.3

• Awiderangeofdentalbenefits,includingmostdiagnostic and preventive services at no additional cost.

• nodeductiblesandnocalendar-yearmaximums.

• nowaitingperiodsexceptfora12-monthwaitingperiod for orthodontic services.

• Affordablefixedcopaymentsforbasicand majorservices.

1. ToqualifyforadentalplanorSpecialtyDuopackage,youmustbeaCaliforniaresident.IfyouwerepreviouslyenrolledinaBlueShieldindividualorfamilydentalplanordental+visionpackage,youmustwaitsixmonthsfromthedateofcancellationbeforeyoucanreapply.

2.SpecialtyDuopackageandValueSmilePPOplansareunderwrittenbyBlueShieldofCaliforniaLife&HealthInsuranceCompany(BlueShieldLife).Pendingregulatoryapproval.

3. Dental providers in California are available through the contracted dental plan administrator. Vision providers in California are available through the contracted vision plan administrator.

Blue Shield offers affordable and comprehensive dental plans that are available with or without a Blue Shield medical plan.1 We also offer a dental + vision package – Specialty DuoSM,2 – that includes comprehensive dental and vision coverage to give you the additional protection your mouth and eyes deserve.

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Benefit summary


Using your dental HMO planWith our dental HMO plan, you'll have access to an extensive network of dental providers without paying deductibles or filling outclaim forms. Plus, it's easy. First, choose a dental provider from our network during enrollment. Then, contact this dental providerfor your dental care. If you have questions or want to switch providers, call Customer Service at (800) 585-8111.


Covered Services Member Pays

Diagnostic and Preventive Services (includes routine oral exams, cleaning, diagnostic casts, and X-rays)

$20 per visit copayment

Full mouth x-rays1 $10 in addition to $20 per visit copayment

Sealants2, 3 $10 per tooth in addition to $20 per visit copayment

Space maintainers2 $40 or billed charged whichever is less for lab fees in addition to $20 per visit copayment

Basic Services (includes anesthesia and restorative destistry) 80% of the Access+ Dentist’s Billed Charges

Major Services (includes cast restorations, endodontics, oral surgery, and periodontics) 80% of the Access+ Dentist’s Billed Charges

Additional Services (includes palliative treatment, applicaiton of desensitizing medication, occlusal guards by report; occlusal adjustment; consultation (diagnostic service provided by dentist or physician other than practitioner roviding treatment), and hospital calls)

80% of the Access+ Dentist’s Billed Charges

Emergency Services

Using Access+ Dentist network Member copayments for Services are as shown above

Using non Access+ Dentist 100% of charge, max $50 per occurrence

Using Out-of-State No coverage

1 Limited to one series in any period of 36 consecutive months.

2 Limited to Members under age 16.

3 One treatment to permanent molars only in any period of 60 consecutive months. Maximum of 4 teeth per lifetime

Many benefits have pre-determined annual schedules and frequency limitations based on last delivery date and dental necessity. If you are unsure about the frequency of when a benefit can be accessed, you can call (888) 702-4171.This is only a summary of the Blue Shield Access+ HMO® Dental Plan. For exact terms and conditions of coverage, including exclusions and limitations, please refer to the Evidence of Coverage and Health Services Agreement.

Access+ HMO® Dental Plan (Dental plan included in the Access+ HMO Plan Package)


Blue Shield of CaliforniaIndividual and Family Dental PPO Plan

Dental PPO Plan Benefit summary

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE AND HEALTH SERVICE AGREEMENT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Finding a network dentist It's easy to choose a dentist. With a broad network of PPO dentists to pick from, you should be able to find one near you. The dental PPO directory is available online in the Find a Provider section at blueshieldca.com, or by calling Customer Service at(888) 702-4171. When you receive care from a network dentist, you pay only the applicable deductibles and copayments, and there are no claim forms to file.

Using a dentist that's not in the network Select any licensed dentist. If you use a dentist that's not in the network, your total out-of-pocket expenses may be higher. You pay at the time of service and afterwards you can file a claim with Blue Shield to receive reimbursement of covered service or you canchoose to have the reimbursement sent to your out-of-network dentist.

In-Network Out-of-Network Calendar Year Deductible (per calendar year for services other than diagnostic and preventive services and enhanced dental benefits for pregnant women)

$50

Annual Benefit Maximum (charges for services above the maximum are your responsibility)

$1,000 (In-Network); $500 (Out-of-Network); No more than $1,000 for In- and Out-of-Network combined

Covered Services In-Network Member Pays

Out-of-Network Max. Plan Payment:

Diagnostic and Preventive ServicesComprehensive oral evaluation $0 $40Periodic oral evaluation $0 $16Intraoral radiographs - complete series (including bitewings) (x-rays) $0 $56Prophylaxis (adult) every 6 months $0 $48Sealant - per tooth (covered to age 15) $0 $22

Routine Services†

Filling (one surface resin composite) $37 per tooth $30 per toothAnterior root canal $156 per tooth $125 per toothMolar root canal $234 per tooth $187 per toothPeriodontal scaling and root planing - four or more teeth per quadrant $65 per quadrant $52 per quadrantExtraction of erupted tooth or exposed root $40 per tooth $32 per tooth

Major Services†

Crown - porcelain/ceramic substrate $265 each crown1 $212 each crown1

Crown - Full cast high noble metal $320 each crown1 $256 each crown1

Osseous surgery (four or more teeth) $263 per quadrant $210 per quadrantPontic - porcelain fused to high noble metal $293 each tooth replaced1 $234 each tooth replaced1

Denture (full upper or lower) $388 per denture $310 per dentureRemoval of impacted tooth - complete bony $113 per tooth $90 per tooth

Orthodontic Services†

Fully banded (two year) case - child2 $2,350 Not coveredFully banded (two year) case - adult2 $2,650 Not covered

† Subject to a waiting period. 1 Precious metals, if used will be charged to the member at the dentist's cost. 2 In order to be covered, orthodontic treatment: must be received in one continuous course of treatment; and must be received in consecutive months.

Orthodontic treatment must not exceed 24 consecutive months.

Many benefits have pre-determined annual schedules and frequency limitations based on last delivery date and dental necessity. If you are unsure about the frequency of when a benefit can be accessed, you can call (800) 585-8111.

This is only a summary of the Blue Shield Dental PPO Plan. For exact terms and conditions of coverage, including exclusions and limitations, please refer to theEvidence of Coverage and Health Services Agreement.


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Blue Shield of California Life & Health Insurance Company Individual and Family Dental Plan

Specialty DuoSM Dental Plan* (Dental plan included in the Specialty Duo Plan Package) Benefit summary

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY CONTRACT SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Finding a network dentistIt's easy to choose a dentist. With a broad network of PPO dentists to pick from, you should be able to find one near you. The dental PPO directory is available online in the Find a Provider section at blueshieldca.com, or by calling Customer Service at(888) 702-4171. When you receive care from a network dentist, you pay only the applicable deductibles and copayments, and there are no claim forms to file.

Using a dentist that's not in the network Select any licensed dentist. If you use a dentist that's not in the network, your total out-of-pocket expenses may be higher. You pay at the time of service and afterwards you can file a claim with Blue Shield Life to receive reimbursement of covered service or you can choose to have the reimbursement sent to your out-of-network dentist.


$50


$1,000 (In-Network); $500 (Out-of-Network); No more than $1,000 for In- and Out-of-Network combined



Diagnostic and Preventive ServicesComprehensive oral evaluation $0 $40Periodic oral evaluation $0 $16 Intraoral radiographs - complete series (including bitewings) (x-rays) $0 $56Prophylaxis (adult) every 6 months $0 $48Sealant - per tooth (covered to age 15) $0 $22

Routine Services †

Filling (one surface resin composite) $37 per tooth $30 per toothAnterior root canal $156 per tooth $125 per toothMolar root canal $234 per tooth $187 per toothPeriodontal scaling and root planing - four or more teeth per quadrant $65 per quadrant $52 per quadrantExtraction of erupted tooth or exposed root $40 per tooth $32 per tooth

Major Services†

Crown - porcelain/ceramic substrate $265 each crown1 $212 each crown1

Crown - Full cast high noble metal $320 each crown1 $256 each crown1

Osseous surgery (four or more teeth) $263 per quadrant $210 per quadrantPontic - porcelain fused to high noble metal $293 each tooth replaced1 $234 each tooth replaced1

Denture (full upper or lower) $388 per denture $310 per denture

Removal of impacted tooth - complete bony $113 per tooth $90 per tooth

Orthodontic Services†

Fully banded (two year) case - child2 $2,350 Not coveredFully banded (two year) case - adult2 $2,650 Not covered

* Pending regulatory approval. † Subject to a waiting period. 1 Precious metals, if used will be charged to the member at the dentist's cost. 2 In order to be covered, orthodontic treatment: must be received in one continuous course of treatment; and must be received in consecutive months.

Orthodontic treatment must not exceed 24 consecutive months.


This is only a summary of the Specialty DuoSM Dental PPO Plan. For exact terms and conditions of coverage, including exclusions and limitations, please refer to the Policy.


Blue Shield of California Life & Health Insurance CompanyIndividual and Family Vision Plan

Specialty DuoSM Vision Plan*(Vision plan included in the Specialty Duo Plan Package) Benefit summary

Exam copayment $0, material copayment $25, frame allowance $100

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Using your vision plan With this vision plan, you have access to an extensive network of vision providers in California and nationwide1. Many of the providers are conveniently located in optical centers at retail stores such as Costco (warehouse4, membership required), LensCrafters, Wal-Mart (wholesale4), Sears, and Target Optical. You also can use an online network provider for 24/7 access to frames and lenses. When you use a network provider, most of your eyecare services are provided at no additional charge.

What your vision plan covers Service and eyewear (90 day waiting period applies to all services)

Coverage when provided by network providers

Maximum payment when provided by non-network provider

Comprehensive Examination - every 12 monthsOphthalmologic 100% up to a maximum of $60

Optometric 100% up to a maximum of $50

Lenses2 - every 24 months3

Single Vision 100% up to a maximum of $43

Bifocal 100% up to a maximum of $60

Trifocal 100% up to a maximum of $75

Aphakic Monofocal or Lenticular Monofocal 100% up to a maximum of $120

Aphakic Multifocal or Lenticular Multifocal 100% up to a maximum of $200

Polycarbonate Lenses for Dependent Children up to a maximum of $100 up to a maximum of $75

Frame - every 24 months up to a maximum of $1004 up to a maximum of $40

Contact Lenses5 - every 24 months3

Non-Elective (Medically Necessary) - Hard6 100% up to a maximum of $200

Non-Elective (Medically Necessary) - Soft6 100% up to a maximum of $250

Elective (Cosmetic/Convenience) - Hard/Soft up to a maximum of $120 up to a maximum of $120

Plano (Non-Prescription) Sunglasses5, 7 up to a maximum of $1004 Not Covered

Diabetes Management Referral8 100% Not Covered

* Pending regulatory approval.

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.

Or:3. Login to My2020EyesDirect.com to access the online

network provider. a. Log on using the primary subscriber's ID or Social

Security Number and the name of the person who is getting the glasses.

b. Create an account. c. Select a frame and the type of lenses. d. Complete the online form (a prescription form is what the

optometrist or ophthalmologist would fill out), and fax or send a copy of the prescription to the network provider for verification or authorize the network provider to contact your Ophthalmologist or Optometrist.

e. Lens and frame costs will be reduced by your covered benefit amounts.

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 from your employer or by logging on to blueshieldca.com. Click download formand 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.

This is only a summary of the Blue Shield Life Specialty DuoSM

Vision Plan. Please refer to the Policy for a detailed description of covered benefits and limitations.

LASIK discount program9

LASIK and PRK correction surgery, an alternative to contacts or glasses, is one of the fastest-growing vision treatments. The discount program gives covered employees access to:

A 15% discount through the TLCVision provider network in California, or

A 20% discount through the QualSight provider network in California.

Discount Vision Program9

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

1 California and Nationwide vision providers are available by arrangement through a contracted vision plan administrator.

2 Fit any frame with an eye size less than 61 mm.

3 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 15 degrees; a difference in vertical prism greater than one prism diopter; or a change in lens type.

4 When the network provider uses wholesale or warehouse pricing, the maximum allowable frame allowance will be as follows: wholesale allowance: $66.04, warehouse allowance $69.09. Network providers using wholesale or warehouse pricing are identified in the Directory of Network Vision Providers. You pay any cost above the allowed amount.

5 In lieu of lenses and frame.

6 A report from the provider and prior authorization from a contracted vision plan administrator is required.

7 For insured persons 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.

8 The diabetes disease management referral program is available to employees who enroll in both Blue Shield medical and vision coverage.

9 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. Insured persons should access those covered services prior to using the discount program.

Insured persons who are not satisfied with products or services received from the discount program may use Blue Shield's grievance process described in the Grievance Process section of the Certificate of Insurance or policy. Blue Shield reserves the right to terminate this program at any time without notice.

Discount programs administered by or arranged through the following independent companies:

1. Discount Vision program - MESVision

2. LASIK Discount Program:

a. Laser Eye Care of California, LLC (within California) and TLCVision (USA) Corporation (outside California)

b. QualSight, Inc. (within California)

Find a network provider nearest you by going to the Find a Provider section on blueshieldca.com, or calling Member Services at(877) 601-9083. You'll find a complete listing of ophthalmologists, optometrists, and opticians.


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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.

Or:3. Login to My2020EyesDirect.com to access the online

network provider. a. Log on using the primary subscriber's ID or Social

Security Number and the name of the person who is getting the glasses.

b. Create an account. c. Select a frame and the type of lenses. d. Complete the online form (a prescription form is what the

optometrist or ophthalmologist would fill out), and fax or send a copy of the prescription to the network provider for verification or authorize the network provider to contact your Ophthalmologist or Optometrist.

e. Lens and frame costs will be reduced by your covered benefit amounts.

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 from your employer or by logging on to blueshieldca.com. Click download formand 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.

This is only a summary of the Blue Shield Life Specialty DuoSM

Vision Plan. Please refer to the Policy for a detailed description of covered benefits and limitations.

LASIK discount program9

LASIK and PRK correction surgery, an alternative to contacts or glasses, is one of the fastest-growing vision treatments. The discount program gives covered employees access to:

A 15% discount through the TLCVision provider network in California, or

A 20% discount through the QualSight provider network in California.

Discount Vision Program9

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

1 California and Nationwide vision providers are available by arrangement through a contracted vision plan administrator.

2 Fit any frame with an eye size less than 61 mm.

3 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 15 degrees; a difference in vertical prism greater than one prism diopter; or a change in lens type.

4 When the network provider uses wholesale or warehouse pricing, the maximum allowable frame allowance will be as follows: wholesale allowance: $66.04, warehouse allowance $69.09. Network providers using wholesale or warehouse pricing are identified in the Directory of Network Vision Providers. You pay any cost above the allowed amount.

5 In lieu of lenses and frame.

6 A report from the provider and prior authorization from a contracted vision plan administrator is required.

7 For insured persons 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.

8 The diabetes disease management referral program is available to employees who enroll in both Blue Shield medical and vision coverage.

9 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. Insured persons should access those covered services prior to using the discount program.

Insured persons who are not satisfied with products or services received from the discount program may use Blue Shield's grievance process described in the Grievance Process section of the Certificate of Insurance or policy. Blue Shield reserves the right to terminate this program at any time without notice.

Discount programs administered by or arranged through the following independent companies:

1. Discount Vision program - MESVision

2. LASIK Discount Program:

a. Laser Eye Care of California, LLC (within California) and TLCVision (USA) Corporation (outside California)

b. QualSight, Inc. (within California)

Find a network provider nearest you by going to the Find a Provider section on blueshieldca.com, or calling Member Services at(877) 601-9083. You'll find a complete listing of ophthalmologists, optometrists, and opticians.

56 BenefitSummaryGuide BenefitSummaryGuide 5756 BenefitSummaryGuide

Blue Shield of California Life & Health Insurance CompanyIndividual and Family Dental PPO Plan

Value SmileSM PPO* Benefit summary

THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Finding a network dentist It's easy to choose a dentist. With a broad network of PPO dentists to pick from, you should be able to find one near you. The dental PPO directory is available online in the Find a Provider section at blueshieldca.com, or by calling Customer Service at(888) 702-4171. When you receive care from a network dentist, you pay only the applicable deductibles and copayments, and there are no claim forms to file.

Using a dentist that's not in the network Select any licensed dentist. If you use a dentist that's not in the network, your total out-of-pocket expenses may be higher. You pay at the time of service, and afterwards you can file a claim with Blue Shield to receive reimbursement of covered service or you can choose to have the reimbursement sent to your out-of-network dentist.


$25


$500 (In-Network); $500 (Out-of-Network); No more than $500 for In- and Out-of-Network combined



Diagnostic and Preventive ServicesComprehensive oral evaluation $0 $40Periodic oral evaluation $0 $16Intraoral radiographs - complete series (including bitewings) (x-rays) $0 $56Prophylaxis (adult) every 6 months $0 $48

Sealant - per tooth (covered to age 15) $0 $22

Minor Restorative Services†

Filling (one surface resin composite) $37 per tooth $30 per tooth

Amalgam one surface, primary or permanent $35 per tooth $28 per tooth

* Pending regulatory approval.

† . Subject to a waiting period.


This is only a summary of the Blue Shield Life Value SmileSM Dental PPO Plan. For exact terms and conditions of coverage, including exclusions and limitations, please refer to the Policy.


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Dental HMO PlanBenefit summary


Using your dental HMO plan With our dental HMO plan, you'll have access to an extensive network of dental providers without paying deductibles or filling outclaim forms. Plus, it's easy. First, choose a dental provider from our network during enrollment. Then, contact this dental providerfor your dental care, including referrals for consultation with plan specialists and emergency services. If you have questions orwant to switch providers, call Customer Service at (800) 585-8111.


Covered Services Member pays Diagnostic and Preventive ServicesComprehensive oral evaluation $0Periodic oral evaluation $0Intraoral radiographs - complete series (including bitewings) (x-rays) $0Prophylaxis (adult) every 6 months $0Sealant - per tooth (covered to age 15) $11

Routine ServicesFilling (one surface resin composite) $18 per tooth Anterior root canal $155 per tooth Molar root canal $290 per tooth Periodontal scaling and root planing - four or more teeth per quadrant $75 per quadrant Extraction of erupted tooth or exposed root $34 per tooth

Major ServicesCrown - porcelain/ceramic substrate $300 each crown1

Crown - Full cast high noble metal $300 each crown1

Osseous surgery (four or more teeth) $303 per quadrant Pontic - porcelain fused to high noble metal $300 each tooth replaced1

Denture (full upper or lower) $400 per denture Removal of impacted tooth - complete bony $125 per tooth

Orthodontic ServicesFully banded (two year) case - child2 $2,350Fully banded (two year) case - adult2 $2,650

1 Precious metals, if used will be charged to the member at the dentist's cost.

2 In order to be covered, orthodontic treatment: must be received in one continuous course of treatment; and must be received in consecutive months. Orthodontic treatment must not exceed 24 consecutive months.


This is only a summary of the Blue Shield Dental HMO Plan. For exact terms and conditions of coverage, including exclusions and limitations, please refer to theEvidence of Coverage and Health Services Agreement.

58 BenefitSummaryGuide

Individual term life insurance plans Individual term life insurance from Blue Shield of California Life & Health Insurance Company (Blue Shield Life) can help you protect your loved ones from the unexpected. Proceeds can help contribute toward funeral expenses and other daily living expenses in uncertain times.

If you request life insurance coverage on the same application used for healthcoverage,underwritingforlifeinsurancecoveragewillbemadeusingtheinformationprovidedonthatapplication.Plus,youwillreceiveone combined bill for both your health plan and life insurance coverage.

EligibilityIndividual term life insurance coverage is available to most members (ages1to64)onanyofourindividualorfamilyhealthplans.Dependentcoverageisnotavailable.MembersofMedicareSupplementplans,HIPAAguaranteed-issueplans,kidsguaranteed-issueplans,andmemberswhoare rated above Tier 4 on their medical plans are ineligible.

IfyoucancelyourBlueShieldhealthplanaftersixmonthsofcontinuouscoverage, you can keep your individual term life insurance policy – even if you leave the state.

Weoffertheoptiontoreturnapolicywithin10days(30daysiftheinsuredisage60to64)forafullrefundifyouarenotsatisfiedforanyreason.

For complete details on individual term life insurance, you can request asamplecopyofthePolicybycallingBlueShieldat(888) 256-3650.

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benefit summary guide - california health insurance€¦ · health coverage. plus, blue shield...

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