Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services. Coverage Period: Beginning On or After 1/1/2018

Transcription

1 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: Beginning On or After 1/1/2018 Blue Shield Gold 80 PPO 0/25 + Child Dental Coverage for: Individual + Family Plan Type: PPO The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately. This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit bsca.com/policies/m _eoc.pdf or call For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call to request a copy. Important Questions Answers Why This Matters: Generally, you must pay all of the costs from providers up to the deductible amount before What is the overall $0 per individual / $0 per family for this plan begins to pay. If you have other family members on the plan each family member deductible? participating providers. must meet their own individual deductible until the total amount of deductible expenses paid by all family members meets the overall family deductible. Are there services covered before you meet your deductible? Are there other deductibles for specific services? What is the out-of-pocket limit for this plan? What is not included in the out-of-pocket limit? Will you pay less if you use a network provider? Do you need a referral to see a specialist? Yes. Preventive care and services listed in your complete terms of coverage. No. $6,000 per individual / $12,000 per family for participating providers; $10,000 per individual / $20,000 per family for non-participating providers. Copayments for certain services, premiums, balance-billing charges, and health care this plan doesn t cover. Yes. See blueshieldca.com/fap or call for a list of network providers. No. This plan covers some items and services even if you haven t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits. You don t have to meet deductibles for specific services. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, the overall family out-of-pocket limit must be met. Even though you pay these expenses, they don t count toward the out-of-pocket limit. This plan uses a provider network. You will pay less if you use a provider in the plan s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider s charge and what your plan pays (balance billing). Be aware, your network provider might use an out-of-network provider for some services (such as lab work). Check with your provider before you get services. You can see the specialist you choose without a referral. 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 of 9

2 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event If you visit a health care provider's office or clinic Services You May Need Primary care visit to treat an injury or illness Participating Provider (You will pay the least) $25/visit What You Will Pay Non-Participating Provider (You will pay the most) 50% coinsurance Specialist visit $55/visit 50% coinsurance Preventive care/screening /immunization No Charge Not Covered Limitations, Exceptions, & Other Important Information None You may have to pay for services that aren t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) Lab & Path: $35/visit X-Ray & Imaging: $55/visit Other Diagnostic Examination: $55/visit Lab & Path: 50% coinsurance X-Ray & Imaging: 50% coinsurance Other Diagnostic Examination: 50% coinsurance up to $350 per day plus 100% of additional charges The services listed are at a freestanding location. Imaging (CT/PET scans, MRIs) Outpatient Radiology Center: 20% coinsurance Outpatient Hospital: 20% coinsurance Outpatient Radiology Center: 50% coinsurance up to $350 per day plus 100% of additional charges Outpatient Hospital: 50% coinsurance up to $350 per day plus 100% of additional charges Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. 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 of 9

3 Common Medical Event If you need drugs to treat your illness or condition More information about prescription drug coverage is available at blueshieldca.com/ formulary If you have outpatient surgery Tier 1 Tier 2 Tier 3 Tier 4 Services You May Need Facility fee (e.g., ambulatory surgery center) What You Will Pay Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most) Retail: Retail: $15/prescription Not Covered Mail Service: Mail Service: $30/prescription Not Covered Retail: $55/prescription Mail Service: $110/prescription Retail: $75/prescription Mail Service: $150/prescription Retail and Network Specialty Pharmacies: 20% coinsurance up to $250/prescription Mail Service: 20% coinsurance up to $500/prescription Ambulatory Surgery Center: 20% coinsurance Outpatient Hospital: 20% coinsurance Retail: Not Covered Mail Service: Not Covered Retail: Not Covered Mail Service: Not Covered Retail: Not Covered Mail Service: Not Covered Ambulatory Surgery Center: 50% coinsurance up to $350 per day plus 100% of additional charges Outpatient Hospital: 50% coinsurance up to $350 per day plus 100% of additional charges Limitations, Exceptions, & Other Important Information Preauthorization is required for select drugs. Failure to obtain preauthorization may result in nonpayment of benefits. Retail: Covers up to a 30-day supply; Mail Service: Covers up to a 90-day supply. Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Retail and Network Specialty Pharmacies: Covers up to a 30-day supply; Specialty Drugs must be obtained at a Network Specialty Pharmacy. Mail Service: Covers up to a 90-day supply None Physician/surgeon fees 20% coinsurance 50% coinsurance None 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 of 9

4 Common Medical Event If you need immediate medical attention If you have a hospital stay If you need mental health, behavioral health, or substance abuse services Services You May Need Emergency room care Emergency medical transportation What You Will Pay Participating Provider Non-Participating Provider (You will pay the least) (You will pay the most) Facility Fee: Facility Fee: $325/visit $325/visit Physician Fee: Physician Fee: No Charge No Charge Limitations, Exceptions, & Other Important Information None $250/transport $250/transport None Urgent care $25/visit 50% coinsurance None Facility fee (e.g., hospital room) 20% coinsurance 50% coinsurance up to $2,000 per day plus 100% of additional charges Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Physician/surgeon fees 20% coinsurance 50% coinsurance None Outpatient services Inpatient services Office Visit: $25/visit Other Outpatient Services: No Charge Partial Hospitalization: No Charge Psychological Testing: No Charge Physician Inpatient Services: 20% coinsurance Hospital Services: 20% coinsurance Residential Care: 20% coinsurance Office Visit: 50% coinsurance Other Outpatient Services: 50% coinsurance Partial Hospitalization: 50% coinsurance up to $350 per day plus 100% of additional charges Psychological Testing: 50% coinsurance Physician Inpatient Services: 50% coinsurance Hospital Services: 50% coinsurance up to $2,000 per day plus 100% of additional charges Residential Care: 50% coinsurance up to $2,000 per day plus 100% of additional charges Preauthorization is required except for office visits. Failure to obtain preauthorization may result in nonpayment of benefits. Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. 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 of 9

5 Common Medical Event Services You May Need Participating Provider (You will pay the least) What You Will Pay Non-Participating Provider (You will pay the most) Limitations, Exceptions, & Other Important Information If you are pregnant If you need help recovering or have other special health needs Office visits No Charge 50% coinsurance Childbirth/delivery professional services Childbirth/delivery facility services 20% coinsurance 50% coinsurance 20% coinsurance Home health care 20% coinsurance Not Covered Rehabilitation services Habilitation services Office Visit: $25/visit Outpatient Hospital: $25/visit Office Visit: $25/visit Outpatient Hospital: $25/visit 50% coinsurance up to $2,000 per day plus 100% of additional charges Office Visit: 50% coinsurance Outpatient Hospital: 50% coinsurance up to $350 per day plus 100% of additional charges Office Visit: 50% coinsurance Outpatient Hospital: 50% coinsurance up to $350 per day plus 100% of additional charges None None Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Coverage limited to 100 visits per member per calendar year None Skilled nursing care Freestanding SNF: 20% coinsurance Hospital-based SNF: 20% coinsurance Freestanding SNF: 20% coinsurance Hospital-based SNF: 50% coinsurance up to $2,000 per day plus 100% of additional charges Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Coverage limited to 100 days per member per benefit period. 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 of 9

6 Common Medical Event If your child needs dental or eye care Services You May Need Participating Provider (You will pay the least) What You Will Pay Non-Participating Provider (You will pay the most) Durable medical equipment 20% coinsurance 50% coinsurance Hospice services No Charge Not Covered Children's eye exam Children's glasses No Charge No Charge Coverage up to a maximum allowance of $30 Coverage up to a maximum allowance of $25 Children's dental check-up No Charge 10% coinsurance Limitations, Exceptions, & Other Important Information Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Preauthorization is required except for pre-hospice consultation. Failure to obtain preauthorization may result in non-payment of benefits. Coverage limited to one exam per member per calendar year. Coverage is limited to one eyeglass frame and eyeglass lenses or contact lenses instead of eyeglasses, up to the benefit per Calendar year. The cost listed is for Single Vision. Coverage for prophylaxis services (cleaning) is limited to two visits per member per calendar year. 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 of 9

7 Excluded Services & Other Covered Services: Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.) Chiropractic Care Hearing Aids Non-emergency care when traveling outside the U.S. Routine foot care Cosmetic surgery Infertility Treatment Private-duty nursing Weight loss programs Dental care (Adult) Long-term care Routine eye care (Adult) Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.) Acupuncture Bariatric surgery Services related to Abortion Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those agencies is: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at x61565 or cciio.cms.gov. Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information about the Marketplace, visit HealthCare.gov or call Your Grievance and Appeals Rights: There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice, or assistance, contact: Blue Shield Customer Service at or the Department of Labor s Employee Benefits Security Administration at EBSA (3272) or dol.gov/ebsa/healthreform. Additionally, you can contact the California Department of Managed Health Care Help at or visit helpline@dmhc.ca.gov or visit Does this plan provide Minimum Essential Coverage? Yes If you don t have Minimum Essential Coverage for a month, you ll have to make a payment when you file your tax return unless you qualify for an exemption from the requirement that you have health coverage for that month. Does this plan meet the Minimum Value Standards? Yes If your plan doesn t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace. 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 of 9

8 Language Access Services: To see examples of how this plan might cover costs for a sample medical situation, see the next section. 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 of 9

9 About these Coverage Examples: This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage. Peg is Having a Baby (9 months of participating pre-natal care and a hospital delivery) Managing Joe s Type 2 Diabetes (a year of routine participating care of a wellcontrolled condition) Mia s Simple Fracture (participating emergency room visit and follow up care) The plan s overall deductible $0 Specialist copayment $55 Hospital (facility) coinsurance 20% Other copayment $35 This EXAMPLE event includes services like: Specialist office visits (prenatal care) Childbirth/Delivery Professional Services Childbirth/Delivery Facility Services Diagnostic tests (ultrasounds and blood work) Specialist visit (anesthesia) Total Example Cost $12,800 In this example, Peg would pay: Cost Sharing Deductibles $0 Copayments $760 Coinsurance $1,792 What isn t covered Limits or exclusions $60 The total Peg would pay is $2,612 The plan s overall deductible $0 Specialist copayment $55 Hospital (facility) coinsurance 20% Other copayment $35 This EXAMPLE event includes services like: Primary care physician office visits (including disease education) Diagnostic tests (blood work) Prescription drugs Durable medical equipment (glucose meter) Total Example Cost $7,400 In this example, Joe would pay: Cost Sharing Deductibles $0 Copayments $2,050 Coinsurance $0 What isn t covered Limits or exclusions $1,783 The total Joe would pay is $3,833 The plan s overall deductible $0 Specialist copayment $55 Hospital (facility) coinsurance 20% Other copayment $55 This EXAMPLE event includes services like: Emergency room care (including medical supplies) Diagnostic test (x-ray) Durable medical equipment (crutches) Rehabilitation services (physical therapy) Total Example Cost $2,500 In this example, Mia would pay: Cost Sharing Deductibles $0 Copayments $1,070 Coinsurance $7 What isn t covered Limits or exclusions $37 The total Mia would pay is $1,114 The plan would be responsible for the other costs of these EXAMPLE covered services. 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 of 9

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

11

12 Blue Shield of California Evidence of Coverage Blue Shield Gold 80 PPO 0/25 + 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 Blue Shield Customer Service 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 should obtain more information before you enroll. Call your prospective doctor, medical group,

13 independent practice association, or clinic, or call the health plan at Blue Shield s Customer Service 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 Customer Service. 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 INDEX 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 Subscriber Bill of Rights As a Blue Shield Subscriber, 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) Have reasonable access to appropriate medical services. 6) 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. 7) A candid discussion of appropriate or Medically Necessary treatment options for your condition, regardless of cost or benefit coverage. 8) 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. 9) Receive preventive health services. 10) Know and understand your medical condition, treatment plan, expected outcome, and the effects these have on your daily living. 11) 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 Physician. 12) Communicate with and receive information from Customer Service in a language you can understand. 13) Know about any transfer to another Hospital, including information as to why the transfer is necessary and any alternatives available. 14) Be fully informed about the Blue Shield grievance procedure and understand how to use it without fear of interruption of health care. 15) Voice complaints or grievances about the health plan or the care provided to you. 16) Participate in establishing Public Policy of the Blue Shield health plan, as outlined in your Evidence of Coverage.

15 Blue Shield of California Subscriber Responsibilities As a Blue Shield Subscriber, you have the responsibility to: 1) Carefully read all Blue Shield 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 Blue Shield 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 your Physician ahead of time when you must cancel. 8) Communicate openly with the Physician you choose so you can develop a strong partnership based on trust and cooperation. 9) Offer suggestions to improve the Blue Shield 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) Treat all Blue Shield personnel respectfully and courteously as partners in good health care. 13) Pay your Premiums, Copayments, Coinsurance and charges for non-covered services on time. 14) For all Mental Health Services, Behavioral Health Treatment, and Substance Use Disorder Services, follow the treatment plans and instructions agreed to by you and the Mental Health Services Administrator (MHSA) and obtain prior authorization as required. 15) Follow the provisions of the Blue Shield Benefits Management Program.

16 Summary of Benefits... 2 Introduction to the Blue Shield of California Health Plan How to Use This Health Plan Choice of Providers Continuity of Care by a Terminated Provider Second Medical Opinion Policy Services for Emergency Care Retail-Based Health Clinics Blue Shield Online Timely Access to Care Health Education and Health Promotion Services Cost-Sharing Submitting a Claim Form Out-of-Area Programs Care for Covered Urgent Care and Emergency Services Outside the United States Inter-Plan Programs BlueCard Program Utilization Management Benefits Management Program Prior Authorization Emergency Admission Notification Inpatient Utilization Management Discharge Planning Case Management Palliative Care Services Principal Benefits and Coverages (Covered Services) Allergy Testing and Treatment Benefits Ambulance Benefits Ambulatory Surgery Center Benefits Bariatric Surgery Benefits Family Planning Benefits Home Health Care Benefits Home Infusion and Home Injectable Therapy Benefits Hospice Program Benefits Hospital Benefits (Facility Services) Medical Treatment of the Teeth, Gums, or Jaw Joints and Jaw Bones Benefits Mental Health, Behavioral Health, and Substance Use Disorder Benefits Orthotics Benefits Outpatient Prescription Drug Benefits Outpatient X-ray, Imaging, Pathology and Laboratory Benefits PKU-Related Formulas and Special Food Products Benefits Podiatric Benefits Pregnancy and Maternity Care Benefits Preventive Health Benefits Professional Benefits Prosthetic Appliances Benefits Reconstructive Surgery Benefits Rehabilitation and Habilitative Services Benefits (Physical, Occupational and Respiratory Therapy) Skilled Nursing Facility Benefits Speech Therapy Benefits (Rehabilitation and Habilitative Services) Transplant Benefits Pediatric Dental Benefits Pediatric Vision Benefits Principal Limitations, Exceptions, Exclusions and Reductions General Exclusions and Limitations Exception for Other Coverage Claims Review Reductions Third Party Liability Coordination of Benefits Conditions of Coverage Eligibility and Enrollment Effective Date of Coverage Premiums (Dues) Grace Period Plan Changes

17 Renewal of the Group Health Service Contract Termination of Benefits (Cancellation and Rescission of Coverage) Extension of Benefits Group Continuation Coverage General Provisions Right of Recovery No Maximum Aggregate Payment Amount Independent Contractors Non-Assignability Plan Interpretation Public Policy Participation Procedure Confidentiality of Personal and Health Information Grievance Process Medical Services External Independent Medical Review Department of Managed Health Care Review Customer Service Definitions Contacting Blue Shield of California

18 Blue Shield of California is an independent member of the Blue Shield Association Summary of Benefits Blue Shield Gold 80 PPO 0/25 + Child Dental Group Plan PPO 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: Full PPO Network This benefit plan uses a specific network of health care providers, called the Full PPO provider network. Providers in this network are called participating providers. You pay less for covered services when you use a participating provider than when you use a non-participating provider. 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 3 or nonparticipating 4 provider Calendar year medical and pharmacy deductible Individual coverage $0 Family coverage $0: individual $0: family Calendar Year Out-of-Pocket Maximum 5 An out-of-pocket maximum is the most a member will pay for covered services each calendar year. Any exceptions are listed in the Notes section at the end of this Summary of Benefits. When using a participating provider 3 Individual coverage $6,000 $10,000 When using any combination of participating 3 or nonparticipating 4 providers 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. Family coverage $6,000: individual $12,000: family $10,000: individual $20,000: family 2 A49322 (01/18) 2

19 Benefits 6 Your payment When using a participating provider 3 CYD 2 applies When using a non-participating provider 4 CYD 2 applies Preventive Health Services 7 $0 Not covered Physician services Primary care office visit $25/visit 50% Specialist care office visit $55/visit 50% Physician home visit $55/visit 50% Physician or surgeon services in an outpatient facility 20% 50% Physician or surgeon services in an inpatient facility 20% 50% Other professional services Other practitioner office visit $25/visit 50% Includes nurses, nurse practitioners, and therapists. Acupuncture services $25/visit 50% Chiropractic services Not covered Not covered Teladoc consultation $5/consult Not covered Family planning Counseling, consulting, and education $0 Not covered Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. $0 Not covered Tubal ligation $0 Not covered Vasectomy 20% Not covered Infertility services Not covered Not covered Podiatric services $55/visit 50% Pregnancy and maternity care 7 Physician office visits: prenatal and initial postnatal $0 50% Physician services for pregnancy termination 20% 50% 3

20 Benefits 6 Your payment When using a participating provider 3 CYD 2 applies When using a non-participating provider 4 CYD 2 applies Emergency services and urgent care Emergency room services $325/visit $325/visit 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. Emergency room physician services $0 $0 Urgent care physician services $25/visit 50% Ambulance services $250/transport $250/transport Outpatient facility services Ambulatory surgery center 20% Outpatient department of a hospital: surgery 20% 50% up to $350/day plus 100% of additional charges 50% up to $350/day plus 100% of additional charges Outpatient department of a hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies Inpatient facility services 20% 50% up to $350/day plus 100% of additional charges Hospital services and stay 20% 50% up to $2000/day plus 100% of additional charges 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 20% Not covered Physician inpatient services 20% Not covered 4

21 Benefits 6 Your payment When using a participating provider 3 CYD 2 applies When using a non-participating provider 4 CYD 2 applies Bariatric surgery services, designated California counties This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non-designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient facility services and Outpatient physician services payments apply. Inpatient facility services 20% Not covered Outpatient facility services 20% Not covered Physician services 20% Not covered 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 50% Outpatient department of a hospital $35/visit 50% up to $350/day plus 100% of additional charges California Prenatal Screening Program $0 $0 X-ray and imaging services Includes diagnostic mammography. Outpatient radiology center $55/visit 50% Outpatient department of a hospital $55/visit 50% up to $350/day plus 100% of additional charges 5

22 Benefits 6 Your payment When using a participating provider 3 CYD 2 applies When using a non-participating provider 4 CYD 2 applies Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, noninvasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG. Office location $55/visit 50% Outpatient department of a hospital $55/visit 50% up to $350/day plus 100% of additional charges Radiological and nuclear imaging services Outpatient radiology center 20% Outpatient department of a hospital 20% 50% up to $350/day plus 100% of additional charges 50% up to $350/day plus 100% of additional charges 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 $25/visit 50% Outpatient department of a hospital Durable medical equipment (DME) $25/visit 50% up to $350/day plus 100% of additional charges DME 20% 50% Breast pump $0 Not covered Orthotic equipment and devices 20% 50% Prosthetic equipment and devices 20% 50% 6

23 Benefits 6 Your payment When using a participating provider 3 CYD 2 applies When using a non-participating provider 4 CYD 2 applies 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 20% Not covered 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 20% Not covered Home health medical supplies 20% Not covered Home infusion agency services 20% Not covered Hemophilia home infusion services 20% Not covered 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 20% 20% Hospital-based SNF 20% 50% up to $2000/day plus 100% of additional charges Hospice program services $0 Not covered 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% 50% Self-management training $0 50% 7

24 Benefits 6 Your payment When using a participating provider 3 CYD 2 applies When using a non-participating provider 4 CYD 2 applies Dialysis services 20% 50% up to $350/day plus 100% of additional charges PKU product formulas and special food products 20% 20% Allergy serum 20% 50% Mental Health and Substance Use Disorder Benefits Your payment Mental health and substance use disorder benefits are provided through Blue Shield's mental health services administrator (MHSA). When using a MHSA participating provider 3 CYD 2 applies When using a MHSA nonparticipating provider 4 CYD 2 applies Outpatient services Office visit, including physician office visit $25/visit 50% 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 $0 50% Partial hospitalization program $0 50% up to $350/day plus 100% of additional charges Psychological testing $0 50% Inpatient services Physician inpatient services 20% 50% Hospital services 20% Residential care 20% 50% up to $2000/day plus 100% of additional charges 50% up to $2000/day plus 100% of additional charges 8

25 Prescription Drug Benefits 8,9 Your payment When using a participating pharmacy 3 CYD 2 applies When using a non-participating pharmacy 4 CYD 2 applies Retail pharmacy prescription drugs Per prescription, up to a 30-day supply. Tier 1 drugs $15/prescription Not covered Tier 2 drugs $55/prescription Not covered Tier 3 drugs $75/prescription Not covered Tier 4 drugs (excluding specialty drugs) 20% up to $250/prescription Not covered Contraceptive drugs and devices $0 Not covered Mail service pharmacy prescription drugs Per prescription, up to a 90-day supply. Tier 1 drugs $30/prescription Not covered Tier 2 drugs $110/prescription Not covered Tier 3 drugs $150/prescription Not covered Tier 4 drugs (excluding specialty drugs) 20% up to $500/prescription Not covered Contraceptive drugs and devices $0 Not covered 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 Not covered Not covered 9

26 Pediatric Benefits Your payment Pediatric benefits are available through the end of the month in which the member turns 19. When using a participating dentist 3 CYD 2 applies When using a non-participating dentist 4 CYD 2 applies Pediatric dental 10 Diagnostic and preventive services Oral exam $0 10% Preventive cleaning $0 10% Preventive x-ray $0 10% Sealants per tooth $0 10% Topical fluoride application $0 10% Space maintainers - fixed $0 10% Basic services Restorative procedures 20% 30% Periodontal maintenance 20% 30% Major services Oral surgery 50% 50% Endodontics 50% 50% Periodontics (other than maintenance) 50% 50% Crowns and casts 50% 50% Prosthodontics 50% 50% Orthodontics (medically necessary) 50% 50% Your payment Pediatric benefits are available through the end of the month in which the member turns 19. When using a participating provider 3 CYD 2 applies When using a non-participating provider 4 CYD 2 applies Pediatric vision 11 Comprehensive eye examination One exam per calendar year. Ophthalmologic visit $0 $0 up to $30 plus 100% of additional charges 10

27 Your payment Pediatric benefits are available through the end of the month in which the member turns 19. When using a participating provider 3 CYD 2 applies When using a non-participating provider 4 CYD 2 applies Optometric visit $0 $0 up to $30 plus 100% of additional charges 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 Up to two pairs per eye per calendar year. Elective (cosmetic/convenience) $0 $0 up to $225 plus 100% of additional charges Standard and non-standard, hard $0 $0 up to $75 plus 100% of additional charges Up to a 3 month supply for each eye per calendar year based on lenses selected. Standard and non-standard, soft $0 $0 up to $75 plus 100% of additional charges Up to a 6 month supply for each eye per calendar year based on lenses selected. Eyeglass frames Collection frames $0 $0 up to $40 plus 100% of additional charges Non-collection frames $0 up to $150 plus 100% of additional charges $0 up to $40 plus 100% of additional charges 11

28 Your payment Pediatric benefits are available through the end of the month in which the member turns 19. When using a participating provider 3 CYD 2 applies When using a non-participating provider 4 CYD 2 applies 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. Single vision $0 Lined bifocal $0 Lined trifocal $0 Lenticular $0 $0 up to $25 plus 100% of additional charges $0 up to $35 plus 100% of additional charges $0 up to $45 plus 100% of additional charges $0 up to $45 plus 100% of additional charges Optional eyeglass lenses and treatments Ultraviolet protective coating (standard only) $0 Not covered Polycarbonate lenses $0 Not covered Standard progressive lenses $0 Not covered Premium progressive lenses $95 Not covered Anti-reflective lens coating (standard only) $35 Not covered Photochromic - glass lenses $25 Not covered Photochromic - plastic lenses $0 Not covered High index lenses $30 Not covered Polarized lenses $45 Not covered Low vision testing and equipment Comprehensive low vision exam $0 Not covered Once every 5 calendar years. 12

29 Your payment Pediatric benefits are available through the end of the month in which the member turns 19. When using a participating provider 3 CYD 2 applies When using a non-participating provider 4 CYD 2 applies Low vision devices $0 Not covered One aid per calendar year. Diabetes management referral $0 Not covered Prior Authorization The following are some frequently-utilized benefits that require prior authorization: Radiological and nuclear imaging services Mental health services, except outpatient office visits Inpatient facility services Hospice program services Home health services from non-participating providers Some prescription drugs (see blueshieldca.com/pharmacy) Pediatric vision non-elective contact lenses and low vision testing and equipment Please review the Evidence of Coverage for more about benefits that require prior authorization. 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 13

30 Notes 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 Using Non-Participating Providers: Non-Participating Providers do not have a contract to provide health care services to Members. When you receive Covered Services from a Non-Participating Provider, you are responsible for both: the Copayment or Coinsurance (once any Calendar Year Deductible has been met), and any charges above the Allowable Amount (which can be significant). Allowable Amount is defined in the EOC. In addition: Any Coinsurance is determined from the Allowable Amount. Any charges above the Allowable Amount are not covered, do not count towards the Out-of-Pocket Maximum, and are your responsibility for payment to the provider. This out-of-pocket expense can be significant. Some Benefits from Non-Participating Providers have the Allowable Amount listed in the Benefits chart as a specific dollar ($) amount. You are responsible for any charges above the Allowable Amount, whether or not an amount is listed in the Benefits chart. 5 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: bariatric surgery: additional covered travel expenses for bariatric surgery dialysis center benefits: dialysis services from a Non-Participating Provider benefit maximum: charges for services after any benefit limit is reached Essential health benefits count towards the OOPM. This benefit plan has a Participating Provider OOPM as well as a combined Participating Provider and Non- Participating Provider OOPM. This means that any amounts you pay towards your Participating Provider OOPM also count towards your combined Participating and Non-Participating Provider 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. 6 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. 7 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. 8 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 14