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1 Resumen de beneficios y cobertura: Qué cubre este plan y cuánto paga por los servicios cubiertos Blue Shield Gold 80 HMO 0/25 Trio + Child Dental INF Período de cobertura: del 1/1/2018 en adelante Cobertura para: Persona + Familia Tipo de plan: HMO El Resumen de beneficios y cobertura (SBC, por sus siglas en inglés) lo ayudará a escoger un plan de salud. El SBC le muestra cómo usted y el plan compartirían el costo de los servicios de atención de la salud cubiertos. NOTA: Se entregará por separado información sobre el costo de este plan (llamado prima ). Este documento es solo un resumen. Para obtener más información sobre su cobertura o conseguir una copia de los términos de cobertura completos, visite bsca.com/policies/m _eoc.pdf o llame al Para ver una definición general de las palabras usadas con frecuencia, como cantidad permitida, facturación del saldo, coseguro, copago, deducible, proveedor u otras palabras subrayadas, consulte el Glosario. Puede ver el Glosario en healthcare.gov/sbc-glossary o llamar al para pedir una copia. Preguntas importantes Respuestas Conceptos importantes: Cuál es el deducible Vea el cuadro de situaciones médicas comunes que está a continuación para conocer los $0. general? costos de los servicios que cubre este plan. Este plan cubre algunos productos y servicios aunque todavía no haya alcanzado la Hay servicios que están cubiertos antes de que alcance su deducible? Sí. La atención preventiva y los servicios que están incluidos en los términos de cobertura completos. cantidad del deducible. Sin embargo, es posible que tenga que pagar un copago o coseguro. Por ejemplo, este plan cubre ciertos servicios preventivos sin costo compartido y antes de que alcance su deducible. Vea la lista de servicios preventivos cubiertos en healthcare.gov/coverage/preventive-care-benefits. Hay otros deducibles para servicios No. No tiene que alcanzar deducibles para servicios específicos. específicos? Cuál es el límite de gastos de bolsillo para este plan? Qué no se incluye en el límite de gastos de bolsillo? Pagará menos si usa un proveedor de la red? Necesita una referencia para ver a un especialista? $6,000 por persona/$12,000 por familia para proveedores participantes. Los copagos para ciertos servicios, las primas y la atención de la salud que no cubra este plan. Sí. Para ver una lista de proveedores de la red, visite blueshieldca.com/fap o llame al Sí. El límite de gastos de bolsillo es la cantidad máxima que podría pagar en un año por los servicios cubiertos. Si tiene otros familiares incluidos en este plan, se tiene que alcanzar el límite de gastos de bolsillo familiar total. Aunque usted pague estos gastos, no cuentan para el límite de gastos de bolsillo. Este plan usa una red de proveedores. Pagará menos si usa un proveedor de la red del plan. Sin embargo, pagará la cantidad máxima si usa un proveedor fuera de la red; además, un proveedor podría enviarle una factura por la diferencia entre lo que cobra el proveedor y lo que paga su plan (facturación del saldo). Tenga en cuenta que su proveedor de la red podría usar un proveedor fuera de la red para algunos servicios (como los análisis de laboratorio). Pregúntele a su proveedor antes de recibir los servicios. Este plan pagará una parte o la totalidad de los costos de los servicios cubiertos en la consulta con un especialista, pero solo si usted tiene una referencia antes de la consulta con el especialista. Blue Shield of California is an independent member of the Blue Shield Association. Covered California is a registered trademark of the State of California. 1 de 9

2 Todos los costos de copago y coseguro que están en este cuadro son después de que haya alcanzado su deducible (si es que hay un deducible). Situación médica común Si visita el consultorio o la clínica de un proveedor de atención de la salud Servicios que puede necesitar Visita de atención primaria para tratar una lesión o enfermedad Visita a un especialista Atención preventiva/pruebas de detección/inmunizaciones Proveedor participante (pagará lo mínimo) $25/visita Especialista de Trio+ Specialist: $55/visita Otro especialista: $55/visita Sin cargo Lo que pagará Proveedor no participante (pagará lo máximo) Sin cobertura Sin cobertura Sin cobertura Limitaciones, excepciones y otra información importante Ninguna Es posible que tenga que pagar por los servicios que no sean preventivos. Pregúntele a su proveedor si los servicios que necesita son preventivos. Después averigüe qué pagará su plan. Si se hace una prueba Prueba de diagnóstico (radiografías, análisis de sangre) Análisis de laboratorio y patología: $35/visita Radiografías y diagnóstico por imágenes: $55/visita Otros exámenes de diagnóstico: $55/visita Análisis de laboratorio y patología: Sin cobertura Radiografías y diagnóstico por imágenes: Sin cobertura Otros exámenes de diagnóstico: Sin cobertura Se necesita autorización previa. Si no consigue una autorización previa, es posible que no se paguen los beneficios. Los servicios mencionados se brindan en un centro independiente. Diagnóstico por imágenes (tomografía computarizada, tomografía por emisión de positrones e imágenes por resonancia magnética) Centro de radiología para pacientes ambulatorios: $275/visita Hospital para pacientes ambulatorios: $275/visita Centro de radiología para pacientes ambulatorios: Sin cobertura Hospital para pacientes ambulatorios: Sin cobertura Se necesita autorización previa. Si no consigue una autorización previa, es posible que no se paguen los beneficios. Blue Shield of California is an independent member of the Blue Shield Association. Covered California is a registered trademark of the State of California. 2 de 9

3 Situación médica común Si necesita medicamentos para tratar su enfermedad o problema de salud Hay más información disponible sobre la cobertura de medicamentos recetados en blueshieldca.com/ formulary Si le tienen que hacer una cirugía ambulatoria Nivel 1 Nivel 2 Nivel 3 Nivel 4 Servicios que puede necesitar Tarifa del centro de atención (p. ej., centro quirúrgico ambulatorio) Lo que pagará Proveedor participante Proveedor no participante (pagará lo mínimo) (pagará lo máximo) Al por menor: Al por menor: $15/receta Sin cobertura Servicio por correo: Servicio por correo: $30/receta Sin cobertura Al por menor: $55/receta Servicio por correo: $110/receta Al por menor: $75/receta Servicio por correo: $150/receta Farmacias especializadas de la red y al por menor: 20% de coseguro hasta un máximo de $250/receta Servicio por correo: 20% de coseguro hasta un máximo de $500/receta Centro quirúrgico ambulatorio: $300/cirugía Hospital para pacientes ambulatorios: $300/cirugía Al por menor: Sin cobertura Servicio por correo: Sin cobertura Al por menor: Sin cobertura Servicio por correo: Sin cobertura Al por menor: Sin cobertura Servicio por correo: Sin cobertura Centro quirúrgico ambulatorio: Sin cobertura Hospital para pacientes ambulatorios: Sin cobertura Limitaciones, excepciones y otra información importante Se necesita autorización previa para ciertos medicamentos. Si no consigue una autorización previa, es posible que no se paguen los beneficios. Al por menor: Cubre un suministro de hasta 30 días. Servicio por correo: Cubre un suministro de hasta 90 días. Se necesita autorización previa. Si no consigue una autorización previa, es posible que no se paguen los beneficios. Farmacias especializadas de la red y al por menor: Cubre un suministro de hasta 30 días. Los medicamentos especializados deben comprarse en una farmacia especializada de la red. Servicio por correo: Cubre un suministro de hasta 90 días Ninguna Tarifas del médico/cirujano $40/visita Sin cobertura Ninguna Blue Shield of California is an independent member of the Blue Shield Association. Covered California is a registered trademark of the State of California. 3 de 9

4 Situación médica común Si necesita atención médica inmediata En caso de hospitalización Servicios que puede necesitar Atención en la sala de emergencias Transporte médico de emergencia Atención urgente Tarifa del centro de atención (p. ej., la habitación del hospital) Lo que pagará Proveedor participante Proveedor no participante (pagará lo mínimo) (pagará lo máximo) Tarifa del centro de atención: Tarifa del centro de atención: $325/visita $325/visita Tarifa del médico: Tarifa del médico: Sin cargo Sin cargo Limitaciones, excepciones y otra información importante Ninguna $250/transporte $250/transporte Ninguna Dentro del área de servicio del plan: $25/visita Fuera del área de servicio del plan: $25/visita $600/día Dentro del área de servicio del plan: Sin cobertura Fuera del área de servicio del plan: $25/visita Sin cobertura Ninguna Se necesita autorización previa. Si no consigue una autorización previa, es posible que no se paguen los beneficios. Tarifas del médico/cirujano Sin cargo Sin cobertura Ninguna Si necesita servicios de salud mental, conductual o por abuso de sustancias adictivas Servicios para pacientes ambulatorios Servicios para pacientes internados Visita al consultorio: $25/visita Otros servicios para pacientes ambulatorios: Sin cargo Hospitalización parcial: Sin cargo Pruebas psicológicas: Sin cargo Servicios para pacientes internados brindados por un médico: Sin cargo Servicios hospitalarios: $600/día Atención en una residencia: $600/día Visita al consultorio: Sin cobertura Otros servicios para pacientes ambulatorios: Sin cobertura Hospitalización parcial: Sin cobertura Pruebas psicológicas: Sin cobertura Servicios para pacientes internados brindados por un médico: Sin cobertura Servicios hospitalarios: Sin cobertura Atención en una residencia: Sin cobertura Se necesita autorización previa, menos para las visitas al consultorio. Si no consigue una autorización previa, es posible que no se paguen los beneficios. Se necesita autorización previa. Si no consigue una autorización previa, es posible que no se paguen los beneficios. Blue Shield of California is an independent member of the Blue Shield Association. Covered California is a registered trademark of the State of California. 4 de 9

5 Situación médica común Si está embarazada Si necesita ayuda para su recuperación u otros cuidados de salud especiales Lo que pagará Servicios que puede Limitaciones, excepciones y otra necesitar Proveedor participante Proveedor no participante información importante (pagará lo mínimo) (pagará lo máximo) Visitas al consultorio Sin cargo Sin cobertura Servicios profesionales para el Ninguna $40/visita Sin cobertura nacimiento/parto Servicios de un centro de atención para el $600/día Sin cobertura Ninguna nacimiento/parto Se necesita autorización previa. Si no consigue una autorización previa, es Atención de la salud en el $30/visita Sin cobertura posible que no se paguen los hogar beneficios. Cobertura limitada a 100 visitas por miembro por año civil. Servicios de rehabilitación Servicios de habilitación Atención de enfermería especializada Visita al consultorio: $25/visita Hospital para pacientes ambulatorios: $25/visita Visita al consultorio: $25/visita Hospital para pacientes ambulatorios: $25/visita Centro de enfermería especializada independiente: $300/día Centro de enfermería especializada en un hospital: $300/día Equipo médico duradero 20% de coseguro Sin cobertura Visita al consultorio: Sin cobertura Hospital para pacientes ambulatorios: Sin cobertura Visita al consultorio: Sin cobertura Hospital para pacientes ambulatorios: Sin cobertura Centro de enfermería especializada independiente: Sin cobertura Centro de enfermería especializada en un hospital: Sin cobertura Ninguna Se necesita autorización previa. Si no consigue una autorización previa, es posible que no se paguen los beneficios. Cobertura limitada a 100 días por miembro por período de beneficios. Se necesita autorización previa. Si no consigue una autorización previa, es posible que no se paguen los beneficios. Blue Shield of California is an independent member of the Blue Shield Association. Covered California is a registered trademark of the State of California. 5 de 9

6 Situación médica común Si su hijo/a necesita atención dental o de la vista Servicios que puede necesitar Cuidados para pacientes terminales Proveedor participante (pagará lo mínimo) Sin cargo Lo que pagará Proveedor no participante (pagará lo máximo) Sin cobertura Examen de la vista para niños Sin cargo Sin cobertura Anteojos para niños Sin cargo Sin cobertura Chequeo dental para niños Sin cargo Sin cobertura Limitaciones, excepciones y otra información importante Se necesita autorización previa, menos para la consulta previa a los cuidados para pacientes terminales. Si no consigue una autorización previa, es posible que no se paguen los beneficios. Cobertura limitada a un examen por miembro por año civil. Cobertura limitada a un marco y a cristales para anteojos o a lentes de contacto en lugar de anteojos, hasta el beneficio por año civil. El costo corresponde a lentes de visión simple. Cobertura de servicios de profilaxis (limpieza) limitada a dos visitas por miembro por año civil. Servicios excluidos y otros servicios cubiertos: Servicios que su plan generalmente NO cubre (Revise los documentos de su póliza o plan para tener más información y ver una lista de otros servicios excluidos). Atención quiropráctica Audífonos Servicio de enfermería privado Atención de los pies de rutina Cirugía estética Atención a largo plazo Atención dental (adultos) Atención que no sea de emergencia cuando viaja fuera de los Estados Unidos Atención de la vista de rutina (adultos) Programas para la pérdida de peso Otros servicios cubiertos (Es posible que se apliquen limitaciones a estos servicios. Esta no es una lista completa. Lea el documento de su plan). Servicios relacionados con el Acupuntura Cirugía bariátrica Tratamiento para la esterilidad aborto Blue Shield of California is an independent member of the Blue Shield Association. Covered California is a registered trademark of the State of California. 6 de 9

7 Sus derechos a seguir con su cobertura: Hay agencias que pueden ayudarlo si quiere seguir con su cobertura después de que termina. La información de contacto de esas agencias es la siguiente: El teléfono del Center for Consumer Information and Insurance Oversight (Centro de Información para el Consumidor y Control de Seguros) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) es ext y la página web es cciio.cms.gov. Es posible que también haya otras opciones de cobertura disponibles para usted, incluso la posibilidad de comprar cobertura de seguro individual por medio del mercado de seguros de salud. Para tener más información sobre el mercado, visite HealthCare.gov o llame al Sus derechos a reclamos y apelaciones: Hay agencias que pueden ayudarlo si tiene una queja contra su plan por negarle una reclamación. Esta queja se llama reclamo o apelación. Para tener más información sobre sus derechos, lea la explicación de beneficios que recibirá por esa reclamación médica. Los documentos de su plan también tienen información completa sobre cómo presentar ante su plan una reclamación, una apelación o un reclamo por cualquier razón. Si quiere recibir más información sobre sus derechos o esta notificación, o si necesita ayuda, llame a Servicio al Cliente de Blue Shield al o a la Employee Benefits Security Administration (Administración para la Seguridad de los Beneficios del Empleado) del Department of Labor (Departamento de Trabajo) al EBSA (3272), o visite dol.gov/ebsa/healthreform. También puede comunicarse con el Centro de Ayuda del Department of Managed Health Care (DMHC, Departamento de Atención de la Salud Administrada) de California al o escribir a la dirección de correo electrónico helpline@dmhc.ca.gov, o bien visitar Brinda este plan una cobertura esencial mínima? Sí. Si no tiene una cobertura esencial mínima durante un mes, tendrá que hacer un pago cuando presente su declaración de impuestos, a menos que califique para la opción de no tener que cumplir con el requisito de contar con cobertura de salud durante ese mes. Cumple este plan con el estándar de valor mínimo? Sí. Si su plan no cumple con los estándares de valor mínimo, es posible que sea elegible para recibir crédito de impuestos para primas para ayudarlo a pagar un plan por medio del mercado. Blue Shield of California is an independent member of the Blue Shield Association. Covered California is a registered trademark of the State of California. 7 de 9

8 Servicios de acceso a idiomas: Para ver cómo este plan podría cubrir costos usando una situación médica de ejemplo, consulte la siguiente sección. Blue Shield of California is an independent member of the Blue Shield Association. Covered California is a registered trademark of the State of California. 8 de 9

9 Sobre estos ejemplos de cobertura: Estos ejemplos no son estimadores de costos. Los tratamientos son solo ejemplos de cómo este plan cubriría la atención médica. Los costos que tenga que pagar serán diferentes según la atención real que reciba, los precios que cobren sus proveedores y muchos otros factores. Preste atención a los costos compartidos (deducibles, copagos y coseguro) y a los servicios excluidos del plan. Use esta información para comparar los costos que pagaría según los distintos planes de salud. Recuerde que estos ejemplos de cobertura son solo para cobertura individual. Embarazo de Peg (9 meses de atención prenatal participante y parto en un hospital) Control de la diabetes tipo 2 de Joe (un año de atención de rutina participante para un problema de salud controlado) Fractura simple de Mía (visita a la sala de emergencias y atención de seguimiento participantes) Deducible general del plan $0 Copago de especialista $55 Copago de hospital (centro) $600 Otro copago $35 Este EJEMPLO incluye servicios como: Visitas al consultorio de especialistas (atención prenatal) Servicios profesionales para el nacimiento/parto Servicios de un centro de atención para el nacimiento/parto Pruebas de diagnóstico (ecografías y análisis de sangre) Visita a un especialista (anestesia) Costo total del ejemplo $12,800 En este ejemplo, Peg pagaría: Costo compartido Deducibles $0 Copagos $1,360 Coseguro $0 Lo que no está cubierto Límites o exclusiones $60 Total que pagaría Peg $1,420 Deducible general del plan $0 Copago de especialista $55 Copago de hospital (centro) $600 Otro copago $35 Este EJEMPLO incluye servicios como: Visitas al consultorio del médico de atención primaria (incluso educación sobre la enfermedad) Pruebas de diagnóstico (análisis de sangre) Medicamentos recetados Equipo médico duradero (medidor de glucosa) Costo total del ejemplo $7,400 En este ejemplo, Joe pagaría: Costo compartido Deducibles $0 Copagos $2,050 Coseguro $0 Lo que no está cubierto Límites o exclusiones $1,783 Total que pagaría Joe $3,833 Deducible general del plan $0 Copago de especialista $55 Copago de hospital (centro) $600 Otro copago $55 Este EJEMPLO incluye servicios como: Atención en la sala de emergencias (incluso suministros médicos) Pruebas de diagnóstico (radiografías) Equipo médico duradero (muletas) Servicios de rehabilitación (fisioterapia) Costo total del ejemplo $2,500 En este ejemplo, Mía pagaría: Costo compartido Deducibles $0 Copagos $1,070 Coseguro $7 Lo que no está cubierto Límites o exclusiones $37 Total que pagaría Mía $1,114 El plan sería responsable de los otros costos relacionados con los servicios cubiertos de este EJEMPLO. Blue Shield of California is an independent member of the Blue Shield Association. Covered California is a registered trademark of the State of California. 9 de 9

10 Blue Shield Gold 80 HMO 0/25 Trio + Child Dental Evidence of Coverage Group

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12 Blue Shield of California Evidence of Coverage Blue Shield Gold 80 HMO 0/25 Trio + Child Dental PLEASE READ THE FOLLOWING IMPORTANT NOTICES ABOUT THIS HEALTH PLAN Packaged Plan: This health plan is part of a package that consists of a health plan and a dental plan which is offered at a package rate. This Evidence of Coverage describes the benefits of the health plan as part of the package This Evidence of Coverage constitutes only a summary of the health plan. The health plan contract must be consulted to determine the exact terms and conditions of coverage. Notice About This Group Health Plan: Blue Shield makes this health plan available to Employees through a contract with the Employer. The Group Health Service Contract (Contract) includes the terms in this Evidence of Coverage, as well as other terms. A copy of the Contract is available upon request. A Summary of Benefits is provided with, and is incorporated as part of, the Evidence of Coverage. The Summary of Benefits sets forth the Member s share-of-cost for Covered Services under the benefit plan. Please read this Evidence of Coverage carefully and completely to understand which services are Covered Services, and the limitations and exclusions that apply to the plan. Pay particular attention to those sections of the Evidence of Coverage that apply to any special health care needs. Blue Shield provides a matrix summarizing key elements of this Blue Shield health plan at the time of enrollment. This matrix allows individuals to compare the health plans available to them. The Evidence of Coverage is available for review prior to enrollment in the plan. For questions about this plan, please contact Shield Concierge at the address or telephone number provided on the back page of this Evidence of Coverage. Notice About Plan Benefits: No Member has the right to receive Benefits for services or supplies furnished following termination of coverage, except as specifically provided under the Extension of Benefits provision, and when applicable, the Continuation of Group Coverage provision in this Evidence of Coverage. Benefits are available only for services and supplies furnished during the term this health plan is in effect and while the individual claiming Benefits is actually covered by this group Contract. Benefits may be modified during the term as specifically provided under the terms of this Evidence of Coverage, the group Contract or upon renewal. If Benefits are modified, the revised Benefits (including any reduction in Benefits or the elimination of Benefits) apply for services or supplies furnished on or after the effective date of modification. There is no vested right to receive the Benefits of this plan. Notice About Reproductive Health Services: Some Hospitals and other providers do not provide one or more of the following services that may be covered under your plan contract and that you or your family member might need: family planning; contraceptive services, including emergency contraception; sterilization, including tubal ligation at the time of labor and delivery; Infertility treatments; or abortion. You

13 should obtain more information before you enroll. Call your prospective doctor, medical group, independent practice association, or clinic, or call the health plan at the Shield Concierge telephone number provided on the back page of this Evidence of Coverage to ensure that you can obtain the health care services that you need. Notice About Contracted Providers: Blue Shield contracts with Hospitals and Physicians to provide services to Members for specified rates. This contractual arrangement may include incentives to manage all services provided to Members in an appropriate manner consistent with the contract. To learn more about this payment system, contact Shield Concierge. The Trio HMO plan offers a limited selection of IPAs and Medical Groups from which Members must choose, and a limited network of Hospitals. Except for Emergency Services, Urgent Services when the Member is out of the Service Area, or when prior authorized, all services must be obtained through the Member s Primary Care Physician. Notice About Health Information Exchange Participation: Blue Shield participates in the California Integrated Data Exchange (Cal INDEX) Health Information Exchange ( HIE ) making its Members health information available to Cal INDEX for access by their authorized health care providers. Cal IN- DEX is an independent, not-for-profit organization that maintains a statewide database of electronic patient records that includes health information contributed by doctors, health care facilities, health care service plans, and health insurance companies. Authorized health care providers (including doctors, nurses, and hospitals) may securely access their patients health information through the Cal INDEX HIE to support the provision of safe, high-quality care. Cal INDEX respects Members right to privacy and follows applicable state and federal privacy laws. Cal INDEX uses advanced security systems and modern data encryption techniques to protect Members privacy and the security of their personal information. The Cal INDEX notice of privacy practices is posted on its website at Every Blue Shield Member has the right to direct Cal INDEX not to share their health information with their health care providers. Although opting out of Cal INDEX may limit your health care provider s ability to quickly access important health care information about you, a Member s health insurance or health plan benefit coverage will not be affected by an election to opt-out of Cal INDEX. No doctor or hospital participating in Cal INDEX will deny medical care to a patient who chooses not to participate in the Cal INDEX HIE. Members who do not wish to have their healthcare information displayed in Cal INDEX, should fill out the online form at or call Cal INDEX at (888)

14 Blue Shield of California Member Bill of Rights As a Blue Shield Member, you have the right to: 1) Receive considerate and courteous care, with respect for your right to personal privacy and dignity. 2) Receive information about all health services available to you, including a clear explanation of how to obtain them. 3) Receive information about your rights and responsibilities. 4) Receive information about your health plan, the services we offer you, the Physicians and other practitioners available to care for you. 5) Select a Primary Care Physician and expect their team of health workers to provide or arrange for all the care that you need. 6) Have reasonable access to appropriate medical services. 7) Participate actively with your Physician in decisions regarding your medical care. To the extent permitted by law, you also have the right to refuse treatment. 8) A candid discussion of appropriate or Medically Necessary treatment options for your condition, regardless of cost or benefit coverage. 9) Receive from your Physician an understanding of your medical condition and any proposed appropriate or Medically Necessary treatment alternatives, including available success/outcomes information, regardless of cost or benefit coverage, so you can make an informed decision before you receive treatment. 10) Receive preventive health services. 11) Know and understand your medical condition, treatment plan, expected outcome, and the effects these have on your daily living. 12) Have confidential health records, except when disclosure is required by law or permitted in writing by you. With adequate notice, you have the right to review your medical record with your Primary Care Physician. 13) Communicate with and receive information from Shield Concierge in a language you can understand. 14) Know about any transfer to another Hospital, including information as to why the transfer is necessary and any alternatives available. 15) Obtain a referral from your Primary Care Physician for a second opinion. 16) Be fully informed about the Blue Shield grievance procedure and understand how to use it without fear of interruption of health care. 17) Voice complaints about the health plan or the care provided to you. 18) Participate in establishing Public Policy of the Blue Shield health plan, as outlined in your Evidence of Coverage or Group Health Service Agreement. 19) Make recommendations regarding Blue Shield s Member rights and responsibilities policy.

15 Blue Shield of California Member Responsibilities As a Blue Shield Member, you have the responsibility to: 1) Carefully read all Blue Shield health plan materials immediately after you are enrolled so you understand how to use your Benefits and how to minimize your out-of- pocket costs. Ask questions when necessary. You have the responsibility to follow the provisions of your Blue Shield membership as explained in the Evidence of Coverage. 2) Maintain your good health and prevent illness by making positive health choices and seeking appropriate care when it is needed. 3) Provide, to the extent possible, information that your Physician, and/or the Plan need to provide appropriate care for you. 4) Understand your health problems and take an active role in developing treatment goals with your medical care provider, whenever possible. 5) Follow the treatment plans and instructions you and your Physician have agreed to and consider the potential consequences if you refuse to comply with treatment plans or recommendations. 6) Ask questions about your medical condition and make certain that you understand the explanations and instructions you are given. 7) Make and keep medical appointments and inform the Plan Physician ahead of time when you must cancel. 8) Communicate openly with the Primary Care Physician you choose so you can develop a strong partnership based on trust and cooperation. 9) Offer suggestions to improve the Blue Shield health plan. 10) Help Blue Shield to maintain accurate and current medical records by providing timely information regarding changes in address, Family status and other health plan coverage. 11) Notify Blue Shield as soon as possible if you are billed inappropriately or if you have any complaints. 12) Select a Primary Care Physician for your newborn before birth, when possible, and notify Blue Shield as soon as you have made this selection. 13) Treat all Plan personnel respectfully and courteously as partners in good health care. 14) Pay your Premiums, Copayments, Coinsurance and charges for non-covered Services on time. 15) For Mental Health Services and Substance Use Disorder Services, follow the treatment plans and instructions agreed to by you and the Mental Health Service Administrator (MHSA).

16 Summary of Benefits... 2 Introduction to the Blue Shield of California Health Plan...12 How to Use This Health Plan...12 Selecting a Primary Care Physician...12 Primary Care Physician Relationship...13 Role of the Primary Care Physician...13 Obstetrical/Gynecological (OB/GYN) Physician Services...13 Referral to Specialty Services...13 Role of the Medical Group or IPA...14 Changing Primary Care Physicians or Designated Medical Group or IPA...14 Trio+ Specialist...15 Trio+ Satisfaction...15 Mental Health, Behavioral Health, and Substance Use Disorder Services...16 Prior Authorization for Mental Health, Behavioral Health, and Substance Use Disorder Services...16 Continuity of Care by a Terminated Provider...17 Continuity of Care for New Members by Non-Contracting Providers...17 Second Medical Opinion...17 Urgent Services...17 Emergency Services...18 NurseHelp 24/7 SM...19 Blue Shield Online...19 Health Education and Health Promotion Services...19 Timely Access to Care...19 Cost Sharing...19 Liability of Subscriber or Member for Payment...20 Limitation of Liability...21 Inter-Plan Programs...21 BlueCard Program...21 Claims for Emergency and Out-of-Area Urgent Services...22 Utilization Management...23 Principal Benefits and Coverages (Covered Services)...23 Acupuncture Benefits...23 Allergy Testing and Treatment Benefits...23 Ambulance Benefits...23 Ambulatory Surgery Center Benefits...23 Bariatric Surgery Benefits...24 Clinical Trial for Treatment of Cancer or Life- Threatening Conditions Benefits...25 Diabetes Care Benefits...26 Durable Medical Equipment Benefits...26 Emergency Room Benefits...27 Family Planning and Infertility Benefits...27 Home Health Care Benefits...28 Home Infusion and Home Injectable Therapy Benefits...28 Hospice Program Benefits...29 Hospital Benefits (Facility Services)...30 Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits...31 Mental Health, Behavioral Health, and Substance Use Disorder Benefits...32 Orthotics Benefits...33 Outpatient Prescription Drug Benefits...33 Outpatient X-ray, Imaging, Pathology and Laboratory Benefits...39 PKU-Related Formulas and Special Food Products Benefits...40 Podiatric Benefits...40 Pregnancy and Maternity Care Benefits...40 Preventive Health Benefits...40 Professional Benefits...41 Prosthetic Appliances Benefits...42 Reconstructive Surgery Benefits...42 Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy)...42 Skilled Nursing Facility Benefits...43 Speech Therapy Benefits (Rehabilitation and Habilitative Services)...43 Transplant Benefits...43 Pediatric Dental Benefits...44 Pediatric Vision Benefits

17 Urgent Services Benefits...90 Principal Limitations, Exceptions, Exclusions and Reductions...91 General Exclusions and Limitations...91 Medical Necessity Exclusion...94 Limitations for Duplicate Coverage...94 Exception for Other Coverage...95 Claims and Services Review...95 Reductions - Third Party Liability...95 Coordination of Benefits...96 Conditions of Coverage...97 Eligibility and Enrollment...97 Effective Date of Coverage...98 Premiums (Dues)...98 Grace Period...98 Plan Changes...98 Renewal of Group Health Service Contract...99 Termination of Benefits (Cancellation and Rescission of Coverage)...99 Extension of Benefits Group Continuation Coverage General Provisions Plan Service Area Liability of Subscribers in the Event of Non-Payment by Blue Shield Right of Recovery No Maximum Lifetime Benefits No Annual Dollar Limits on Essential Health Benefits Payment of Providers Facilities Independent Contractors Non-Assignability Plan Interpretation Public Policy Participation Procedure Confidentiality of Personal and Health Information Access to Information Grievance Process Medical Services Mental Health, Behavioral Health, and Substance Use Disorder Services External Independent Medical Review Department of Managed Health Care Review Shield Concierge Definitions Contacting Blue Shield of California Infertility Benefits

18 Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Blue Shield Gold 80 HMO 0/25 Trio + Child Dental Group Plan HMO Benefit Plan This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California benefit plan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage (EOC). 1 Please read both documents carefully for details. Provider Network: Trio ACO HMO Network This benefit plan uses a specific network of health care providers, called the Trio ACO HMO provider network. Medical groups, independent practice associations (IPAs), and physicians in this network are called participating providers. You must select a primary care physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this plan. You can find participating providers in this network at blueshieldca.com. Calendar Year Deductibles (CYD) 2 A calendar year deductible (CYD) is the amount a member pays each calendar year before Blue Shield pays for covered services under the benefit plan. When using a participating provider 3 Calendar year medical and pharmacy deductible Individual coverage $0 Family coverage $0: individual $0: family Calendar Year Out-of-Pocket Maximum 4 An out-of-pocket maximum is the most a member will pay for covered services each calendar year. Any exceptions are listed in the EOC. Individual coverage $6,000 Family coverage When using a participating provider 3 $6,000: individual $12,000: family No Lifetime Benefit Maximum Under this benefit plan there is no dollar limit on the total amount Blue Shield will pay for covered services in a member s lifetime. 2

19 Benefits 5 Your payment When using a participating provider 3 CYD 2 applies Preventive Health Services 6 $0 Physician services Primary care office visit Trio+ specialist care office visit Other specialist care office visit Physician home visit $25/visit $55/visit $55/visit $55/visit Physician or surgeon services in an outpatient facility $40 Physician or surgeon services in an inpatient facility $0 Other professional services Other practitioner office visit Includes nurses, nurse practitioners, and therapists. Acupuncture services Chiropractic services Teladoc consultation Family planning $25/visit $25/visit Not covered $5/consult Counseling, consulting, and education $0 Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. Tubal ligation $0 Vasectomy $40/surgery Infertility services 50% Podiatric services Pregnancy and maternity care 6 $0 $55/visit Physician office visits: prenatal and initial postnatal $0 Physician services for pregnancy termination Emergency services and urgent care Emergency room services If admitted to the hospital, this payment for emergency room services does not apply. Instead, you pay the participating provider payment under Inpatient facility services/ Hospital services and stay. $40/surgery $325/visit Emergency room physician services $0 Urgent care physician services Inside your primary care physician s service area, services must be provided or referred by your primary care physician or medical group/ipa. Services outside your primary care physician s service area are also covered. Services inside your primary care physician s service area not provided or referred by your primary care physician or medical group/ipa are not covered. Ambulance services $25/visit $250/transport 3

20 Benefits 5 Your payment When using a participating provider 3 CYD 2 applies Outpatient facility services Ambulatory surgery center Outpatient department of a hospital: surgery Outpatient department of a hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies $300/surgery $300/surgery 20% Inpatient facility services Hospital services and stay Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies. Special transplant facility inpatient services $600/day up to 5 days/admission $600/day up to 5 days/admission Physician inpatient services $0 Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services that are diagnostic, non-preventive health services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test. Laboratory center $35/visit Outpatient department of a hospital $35/visit California Prenatal Screening Program $0 X-ray and imaging services Includes diagnostic mammography. Outpatient radiology center $55/visit Outpatient department of a hospital $55/visit Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG. Office location $55/visit Outpatient department of a hospital $55/visit Radiological and nuclear imaging services Outpatient radiology center $275/visit Outpatient department of a hospital $275/visit 4

21 Benefits 5 Your payment When using a participating provider 3 CYD 2 applies Rehabilitation and habilitative services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. There is no visit limit for rehabilitation or habilitative services. Office location Outpatient department of a hospital $25/visit $25/visit Durable medical equipment (DME) DME 20% Breast pump $0 Orthotic equipment and devices $0 Prosthetic equipment and devices $0 Home health services Up to 100 visits per member, per calendar year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible period, except hemophilia and home infusion nursing visits. Home health agency services Includes home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist. Home visits by an infusion nurse $30/visit $30/visit Home health medical supplies $0 Home infusion agency services $0 Hemophilia home infusion services $0 Includes blood factor products. Skilled nursing facility (SNF) services Up to 100 days per member, per benefit period, except when provided as part of a hospice program. All days count towards the limit, including days during any applicable deductible period and days in different SNFs during the calendar year. Freestanding SNF Hospital-based SNF $300/day up to 5 days/admission $300/day up to 5 days/admission Hospice program services $0 Includes pre-hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care. Other services and supplies Diabetes care services Devices, equipment, and supplies 20% 5

22 Benefits 5 Your payment When using a participating provider 3 Self-management training $0 Dialysis services 20% PKU product formulas and special food products $0 Allergy serum 20% CYD 2 applies Mental Health and Substance Use Disorder Benefits Mental health and substance use disorder benefits are provided through Blue Shield's mental health services administrator (MHSA). Outpatient services Your payment When using a MHSA participating provider 3 CYD 2 applies Office visit, including physician office visit Other outpatient services, including intensive outpatient care, behavioral health treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility setting, and office-based opioid treatment $25/visit Partial hospitalization program $0 Psychological testing $0 Inpatient services Physician inpatient services $0 Hospital services Residential care $0 $600/day up to 5 days/admission $600/day up to 5 days/admission Prescription Drug Benefits 7,8 Your payment When using a participating pharmacy 3 CYD 2 applies Retail pharmacy prescription drugs Per prescription, up to a 30-day supply. Tier 1 drugs $15/prescription Tier 2 drugs $55/prescription Tier 3 drugs $75/prescription Tier 4 drugs (excluding specialty drugs) 20% up to $250/prescription Contraceptive drugs and devices $0 Mail service pharmacy prescription drugs Per prescription, up to a 90-day supply. Tier 1 drugs Tier 2 drugs Tier 3 drugs Tier 4 drugs (excluding specialty drugs) $30/prescription $110/prescription $150/prescription 20% up to $500/prescription 6

23 Prescription Drug Benefits 7,8 Your payment When using a participating pharmacy 3 Contraceptive drugs and devices $0 CYD 2 applies Specialty drugs Per prescription. Specialty drugs are covered at tier 4 and only when dispensed by a network specialty pharmacy. Specialty drugs from non-participating pharmacies are not covered except in emergency situations. Oral anticancer drugs Per prescription, up to a 30-day supply. 20% up to $250/prescription 20% up to $200/prescription Pediatric Benefits Pediatric benefits are available through the end of the month in which the member turns 19. Your payment When using a participating dentist 3 CYD 2 applies Pediatric dental 9 Diagnostic and preventive services Oral exam $0 Preventive cleaning $0 Preventive x-ray $0 Sealants per tooth $0 Topical fluoride application $0 Space maintainers - fixed $0 Basic services Restorative procedures Periodontal maintenance Major services Oral surgery Endodontics Periodontics (other than maintenance) Crowns and casts Prosthodontics See Dental Copay Schedule in Evidence of Coverage See Dental Copay Schedule in Evidence of Coverage See Dental Copay Schedule in Evidence of Coverage See Dental Copay Schedule in Evidence of Coverage See Dental Copay Schedule in Evidence of Coverage See Dental Copay Schedule in Evidence of Coverage See Dental Copay Schedule in Evidence of Coverage Orthodontics (medically necessary) $1,000 7

24 Pediatric benefits are available through the end of the month in which the member turns 19. Your payment When using a participating provider 3 CYD 2 applies Pediatric vision 10 Comprehensive eye examination One exam per calendar year. Ophthalmologic visit $0 Optometric visit $0 Eyewear/materials One eyeglass frame and eyeglass lenses, or contact lenses instead of eyeglasses, up to the benefit per calendar year. Any exceptions are noted below. Contact lenses Non-elective (medically necessary) - hard or soft $0 Up to two pairs per eye per calendar year. Elective (cosmetic/convenience) Standard and non-standard, hard $0 Up to a 3 month supply for each eye per calendar year based on lenses selected. Standard and non-standard, soft $0 Up to a 6 month supply for each eye per calendar year based on lenses selected. Eyeglass frames Collection frames $0 Non-collection frames Eyeglass lenses Lenses include choice of glass or plastic lenses, all lens powers (single vision, bifocal, trifocal, lenticular), fashion or gradient tint, scratch coating, oversized, and glass-grey #3 prescription sunglasses. $0 up to $150 plus 100% of additional charges Single vision $0 Lined bifocal $0 Lined trifocal $0 Lenticular $0 Optional eyeglass lenses and treatments Ultraviolet protective coating (standard only) $0 Polycarbonate lenses $0 Standard progressive lenses $0 Premium progressive lenses $95 Anti-reflective lens coating (standard only) $35 Photochromic - glass lenses $25 Photochromic - plastic lenses $0 High index lenses $30 Polarized lenses $45 8

25 Your payment Pediatric benefits are available through the end of the month in which the member turns 19. Low vision testing and equipment When using a participating provider 3 Comprehensive low vision exam $0 Once every 5 calendar years. Low vision devices $0 One aid per calendar year. Diabetes management referral $0 CYD 2 applies Notes 1 Evidence of Coverage (EOC): The Evidence of Coverage (EOC) describes the benefits, limitations, and exclusions that apply to coverage under this benefit plan. Please review the EOC for more details of coverage outlined in this Summary of Benefits. You can request a copy of the EOC at any time. Defined terms are in the EOC. Refer to the EOC for an explanation of the terms used in this Summary of Benefits. 2 Calendar Year Deductible (CYD): Calendar Year Deductible explained. A deductible is the amount you pay each calendar year before Blue Shield pays for Covered Services under the benefit plan. If this benefit plan has any Calendar Year Deductible(s), Covered Services subject to that Deductible are identified with a check mark ( ) in the Benefits chart above. 3 Using Participating Providers: Participating Providers have a contract to provide health care services to Members. When you receive Covered Services from a Participating Provider, you are only responsible for the Copayment or Coinsurance, once any Calendar Year Deductible has been met. Your payment for services from Other Providers. You will pay the Copayment or Coinsurance applicable to Participating Providers for Covered Services received from Other Providers. However, Other Providers do not have a contract to provide health care services to Members and so are not Participating Providers. Therefore, you will also pay all charges above the Allowable Amount. This out-of-pocket expense can be significant. 4 Calendar Year Out-of-Pocket Maximum (OOPM): Your payment after you reach the calendar year OOPM. You will continue to be responsible for Copayments or Coinsurance for the following Covered Services after the Calendar Year Out-of-Pocket Maximum is met: benefit maximum: charges for services after any benefit limit is reached Essential health benefits count towards the OOPM. Family coverage has an individual OOPM within the family OOPM. This means that the OOPM will be met for an individual who meets the individual OOPM prior to the family meeting the family OOPM within a Calendar Year. 5 Separate Member Payments When Multiple Covered Services are Received: Each time you receive multiple Covered Services, you might have separate payments (Copayment or Coinsurance) for each service. When this happens, you may be responsible for multiple Copayments or Coinsurance. For example, you may owe an office visit Copayment in addition to an allergy serum Copayment when you visit the doctor for an allergy shot. 9

26 Notes 6 Preventive Health Services: If you only receive Preventive Health Services during a physician office visit, there is no Copayment or Coinsurance for the visit. If you receive both Preventive Health Services and other Covered Services during the physician office visit, you may have a Copayment or Coinsurance for the visit. 7 Outpatient Prescription Drug Coverage: Medicare Part D-creditable coverage- This benefit 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 benefit plan s prescription drug coverage is creditable, you do not have to enroll in Medicare Part D while you maintain this coverage; however, you should be aware that if you have a later break in this coverage of 63 days or more before enrolling in Medicare Part D you could be subject to payment of higher Medicare Part D premiums. 8 Outpatient Prescription Drug Coverage: Brand Drug coverage when a Generic Drug is available. If you, the Physician, or Health Care Provider, select a Brand Drug when a Generic Drug equivalent is available, you are responsible for the difference between the cost to Blue Shield for the Brand Drug and its Generic Drug equivalent plus any applicable Drug tier Copayment or Coinsurance. This difference in cost will not count towards any Calendar Year pharmacy Deductible, medical Deductible, or the Calendar Year Out-of-Pocket Maximum. Request for Medical Necessity Review. If you or your Physician believes a Brand Drug is Medically Necessary, either person may request a Medical Necessity Review. If approved, the Brand Drug will be covered at the applicable Drug tier Member payment. Short-Cycle Specialty Drug program. This program allows initial prescriptions for select Specialty Drugs to be filled for a 15-day supply. When this occurs, the Copayment or Coinsurance will be pro-rated. 9 Pediatric Dental Coverage: Pediatric dental benefits are provided through Blue Shield s Dental Plan Administrator (DPA). Orthodontic Covered Services. The Copayment or Coinsurance for Medically Necessary orthodontic Covered Services applies to a course of treatment even if it extends beyond a Calendar Year. This applies as long as the Member remains enrolled in the Plan. 10 Pediatric Vision Coverage: Pediatric vision benefits are provided through Blue Shield s Vision Plan Administrator (VPA). Coverage for frames. If frames are selected that are more expensive than the Allowable Amount established for frames under this Benefit, you pay the difference between the Allowable Amount and the provider s charge. Collection frames are covered with no member payment from Participating Providers. Retail chain Participating Providers do not usually display the frames as collection, but a comparable selection of frames is maintained. Non-collection frames are covered up to an Allowable Amount of $150; however, if the Participating Provider uses: wholesale pricing, then the Allowable Amount will be up to $ warehouse pricing, then the Allowable Amount will be up to $ Participating Providers using wholesale pricing are identified in the provider directory. A49316 (1/18) 10