choosing your health plan - California Health Insurance · choosing your health plan 1 We’re here for you When it comes to your health, we’re here to support you. We have the

blueshieldca.com

Effective March 1, 2012

choosing your health plan

for individuals and families

hello Thank you for your interest in Blue Shield. We know your healthcare needs are as unique as you are, and can change as your life changes. That’s why Blue Shield offers a wide selection of well-designed health plan options for you to choose from. And selecting the perfect health plan can be simple. This booklet will help you compare, choose, and apply for the plan that best meets your unique wants and needs.

This booklet highlights products available from Blue Shield. It provides you with the detailed benefit information needed to make informed choices about health coverage.* The plans included in this booklet are available for new Blue Shield customers. Existing Blue Shield customers who have “grandfathered” status on their plan as a result of the Affordable Care Act have benefits that differ from those contained in this booklet.

This booklet is a summary of plan information and is not a contract. The actual complete terms and conditions of a plan’s benefits and coverage, limitations, and exclusions are located in the Evidence of Coverage and Health Service Agreement (EOC) or Policy for Individuals and Families (Policy). We’ll send you your EOC/Policy if your application is approved. If you have any questions or would like a copy of the EOC/Policy before you apply, call us at (800) 431-2809.

PLEASE NOTE: This booklet should be accompanied by the Important Legal Information booklet, explaining general plan exclusions and limitations. You should read both documents together. If you do not have the Important Legal Information booklet, please obtain a copy by contacting your broker or calling Blue Shield at (800) 431-2809.

* Please consider your options carefully before failing to maintain or renew coverage for a child for whom you are responsible. If you attempt to obtain new individual coverage for that child, the rate for the same coverage may be higher than the rate you pay now. If you apply for coverage for your child at any time other than during a special enrollment period, and your child did not maintain health coverage during the 90-day period prior to the signature date of the application, a 20% surcharge will apply for the first 12 months of coverage. For additional information, visit blueshieldca.com/bsc/findaplan/ifp/look/kids.jhtml.

table of contents

We’re here for you ................................. 1

Wellness resources that take care of YOU ................................................... 2

Important words you should know ..... 3

How a health plan works ..................... 5

Find the right plan ................................. 6

Plan comparison chart ......................... 8

Dental plans, dental + vision, and term life insurance coverage ............9

How to apply .........................................12

Health plan details ...............................13

Dental, dental + vision, and term life insurance coverage rates ........ 102

Dental and dental + vision plan details ...................................... 103

FAQs ..................................................... 106

choosing your health plan 1

We’re here for you

When it comes to your health, we’re here to support you. We have the experience and stability you want in a health plan. Blue Shield of California has been providing millions of Californians with access to quality, affordable health coverage for over 70 years, and Blue Shield of California Life & Health Insurance Company has been serving Californians for more than 50 years.

With Blue Shield, you have access to a broad selection of plans that offer you the coverage that best meets your needs.* Because we have some of the largest provider networks in the state, you can get the care you need from doctors you probably already know and trust. And because we also offer dental, dental + vision,† and term life insurance† coverage, Blue Shield can manage all of your health and life insurance coverage needs.

All Blue Shield medical plans offer:

Preventive care – including a gynecological exam, an annual physical exam, or well-baby exams – at no additional cost before you meet your deductible

Generic prescription drug coverage

Physician office visits, with copayments starting as low as $30!

Additional benefits of being a Blue Shield member

A broad choice of providers – Over 65,000 PPO and 34,000 HMO physicians so you can find a doctor nearby

NurseHelp 24/7SM which can help answer your health concerns, any time day or night, at no additional charge

Optional dental,‡ dental + vision,‡ and term life insurance coverage to complete your total health package

Online tools and wellness programs at no extra charge to help you take control of your health

Knowledgeable customer service representatives to answer all your questions

A wide range of programs, services, and resources that complement your coverage, so you can stay on top of your health and achieve your health goals

* To be eligible for a Blue Shield Individual and Family Plan, you must be a California resident under age 65. You must apply for coverage. If you have other medical coverage, you must cancel that coverage if you are approved for coverage with Blue Shield.

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

‡ You must be a California resident at the time of enrollment. Benefits are only available within the state of California, except in emergency situations. If you had a Blue Shield individual and family dental plan or Specialty Duo package cancelled, you must wait six months from the date of cancellation before you can reapply.

2 choosing your health plan

Wellness resources that take care of YOU

We believe that encouraging wellness goes beyond your basic health plan benefits. That’s why, as a Blue Shield member, you will have access to a wide range of programs, tools, and services that can help you get and stay healthy – at no additional charge.

Just a phone call away

NurseHelp 24/7With our NurseHelp 24/7SM program, you can talk to a nurse anytime, day or night, to learn about a condition, evaluate treatment options, develop a healthier lifestyle, and more.

With a simple click of your mouse

Our innovative website, blueshieldca.com, offers around-the-clock access to valuable tools, health resources, and wellness information. When you register as a member at blueshieldca.com, you can:

• Locatenetworkdoctors,hospitals,pharmacies,dentists,optometrists,dermatologists,mentalhealthproviders, chiropractors, and acupuncturists.

• Explorebenefits,viewclaims,andpayyourdues/premiums.

• Searchouronlinedrugformulary(BlueShieldpreferreddrugs)toseeifyourprescriptioniscoveredand if a generic version is available.

• Signupforhealthmanagementprogramsthatofferresourcesandsupportforconditionssuchasasthma and diabetes. You can also enroll in our prenatal program.

• Comparehospitalsandlearnabouttreatmentoptions.

• ParticipateinHealthyLifestyleRewardstogetinshape,eatright,reducestress,orquitsmoking.


Important words you should know

Here are some helpful definitions of common words you may encounter in this booklet. For the contractual definitions of terms, see the EOC/Policy.

Allowable amountThe dollar amount considered payment-in-full for services provided by Blue Shield and our network of healthcare providers.

BenefitsServices and supplies a member is entitled to receive according to the plan’s terms.

Brand-name prescription drugA drug produced and sold under the original manufacturer’s brand name. Many brand- name drugs are included in the Blue Shield Drug Formulary.

Calendar yearThe period starting at 12:01 a.m. on January 1 and ending at 11:59 p.m. on December 31 of the same year.

CoinsuranceThe percentage of the cost of benefits for which you are responsible after meeting your annual medical deductible (if applicable). For example, if the allowable amount is $100 and your coinsurance is 20%, you pay $20 and Blue Shield pays $80.

CopaymentThe fixed dollar amount you pay for a benefit, such as a doctor’s visit or prescription (if applicable). If your office visit copayment is $20, you would pay that amount each time you see your doctor. Note that some plans may not pay for some services until after you meet your deductible.

Copayment/coinsurance maximumThe dollar limit on the amount you have to pay for specified covered services in a calendar year. On most plans, the amount you pay in copayments and/or coinsurance for most benefits applies toward this maximum.

DeductibleThe amount you pay in a calendar year for covered services before you become eligible to receive benefits (if applicable). For some covered services, such as generic prescription drugs and preventive care, your plan may pay for treatment before you meet the deductible.

Evidence of Coverage/PolicyThe contract that describes your healthcare benefits.

FormularyOur list of preferred generic and brand-name prescription drugs. Formulary drugs typically cost you less.

MemberAnyone who is covered under the contract. Members can include the subscriber, a spouse or partner, and children.

Non-preferred provider (PPO plans only)A provider that is not in the Blue Shield PPO network (also called a non-network provider).


Out-of-pocket maximumA dollar limit on the total amount you have to pay for many covered services in a calendar year, including the deductible.

Personal Physician (HMO plans only)The network doctor who serves as the HMO member’s primary healthcare provider and provides and coordinates all of the member’s care.

Preferred provider (PPO plans only)A provider that is part of the Blue Shield PPO network (also called a network provider). PPO members typically pay less when they use preferred providers.

Prior authorizationAn advance approval from Blue Shield that your plan will cover any of the costs associated with a particular benefit.

SubscriberThe person in whose name a contract is written.


How a health plan works

Understanding how health plans work can be confusing. To make it easier, here are some benefit descriptions using scenarios* of individuals and families to help explain how benefits work.

$0 after deductible (PPO)Meet Jesse:

?

Jesse’s Shield SavingsSM 3500 plan has a medical deductible of $3,500.

Jesse uses several of his plan’s benefits throughout the year, the costs of which count toward his deductible. By June, he meets his plan’s deductible of $3,500.

Afterward he goes to the hospital for an inpatient stay, and since he has already met his deductible, the visit will cost him $0 ($0 after deductible).

$250 after deductible (HMO)Meet Jason:

?

Jason has the Access+ HMO® package with a $2,000 medical deductible.

Jason experienced an injury requiring an inpatient stay at the hospital. The cost for his hospitalization is $20,000, but Jason will only be responsible for paying $2,250: his $2,000 medical deductible plus a $250 copayment.

$0 after copayment/coinsurance maximum (PPO)Meet Lucia:

?

Lucia’s Vital ShieldSM Plus 900 plan has a copayment/coinsurance maximum of $3,900.

Lucia uses several of her plan’s benefits throughout the year, the costs of which count toward her copayment/coinsurance maximum. By October, she has met the plan’s copayment/coinsurance maximum of $3,900.

Later, she has an X-ray taken, and since she has already met the copayment/coinsurance maximum, the visit will cost her $0 ($0 after copayment/coinsurance maximum).

$35 after $500 brand Rx deductible (PPO)Meet Jessica:

?

Jessica has the BalanceSM Plan 2500withabrandRxdeductibleof$500.

When she gets her brand-name prescription filled, she pays 100% of Blue Shield’s contracted rate until she spends $500 on brand-name drugs, therefore meeting the brandRxdeductible.

InJulyJessicameetsthe$500brandRxdeductible,sothenexttimeshegetsherbrand-name prescription filled, she pays only $35($35after$500brandRxdeductible).

* For illustrative purposes only. Situations may vary depending on the specifics of the health plan, health plan limits, and other factors. Amounts shown are for services from network providers. HMO plan members must choose a Personal Physician. Except for emergencies, the Personal Physician will coordinate all your medical care, including referrals to specialists, hospitals, and other covered non-physician healthcare practitioners.


Find the right plan

Without health coverage, unexpected medical events can really add up. Did you know that an average day in the hospital can cost more than $15,912?* But with the right health plan you don’t need to worry, because that day in the hospital can cost you much less. In addition, doctor visits and prescriptions are much more affordable when you have the right plan to fit your needs.

Given the importance of selecting a health plan that’s right for you, we suggest a few simple questions to help guide your choice and make it easier:

What kind of coverage would suit you best?Choosing a PPO or an HMO plan provides you with different experiences. With a PPO plan, you may visit any licensed doctor – in or out of the physician network – without a referral from a Personal Physician. With an HMO plan, you and all family members covered by the plan must live or work in an area served by the plan and access all your care in the plan provider network, through the Personal Physician you choose.

What plan will fit your budget?There are two things to consider when calculating your healthcare costs: your monthly rate and your out-of-pocket costs.

1. Once you have narrowed down your choice of plans, ask your broker for a rate quote to estimate your monthly rate.

2. When determining out-of-pocket costs, you need to think about:

•Whenyouvisitaphysician,whatdoyouwanttopay?

If you go to the doctor often, you may prefer a plan with a lower copayment. What level of copayment feels right for how often you go? Compare “physician office visit copayments” in the Plan Comparison Chart on page 8.

* Based on an average day’s billed charges for a Blue Shield Individual and Family Plan in 2010. Costs may vary depending on the carrier, region, and provider.


•Whatisthemostyouwanttopayeachyearformedicalcarebeforeyourplanbeginspaying?

This is your annual deductible. Typically, the higher the deductible, the lower your monthly rate. Compare the “annual medical deductible” for each plan in the Plan Comparison Chart on page8.Restassured,allourplansprovidepreventivecarebeforeyouhavetomeetthe annual deductible.

•Whatisthemaximumamountyoucanaffordincaseofanaccident?

Compare the “annual out-of-pocket maximum” for each plan in the Plan Comparison Chart on page 8. An out-of-pocket maximum is the maximum dollar limit you have to pay for many covered services in a calendar year.

•Doyouprefergenericorbrand-nameprescriptiondrugs?

Compare each plan’s “drug coverage” in the Plan Comparison Chart on page 8. You can choose plans that offer generic drug coverage only for a lower monthly rate.

After you narrow down your health plan choices, refer to the health plan summaries found later in this guide for more detailed information on each plan.

Is your current doctor part of our extensive network?With some of the largest provider networks in the state, chances are your current physician is already part of Blue Shield’s networks. See for yourself with our Find a Provider tool at blueshieldca.com.


Plan comparison chart The following chart offers a high-level comparison of all health plans offered by Blue Shield. Additional details are provided in the health plan summaries which follow.

Physician office visit copayments1

(you pay)

Annual medical deductible

Annual copayment/coinsurance/out-of-pocket maximum2

Monthly rates starting at3

Maternity coverage

Prescription drug coverage (formulary)

HSA- compatible

Vital Shield* 2900 $40 for first visit1 $2,900 $5,900 $83 Generic only

900 $40 for first visit1 $900 $4,900 $102 Generic only

Vital Shield Plus* 2900 Generic Rx $30 for first 4 visits1 $2,900 $4,900 $105 Generic only

2900 $30 for first 4 visits1 $2,900 $4,900 $126 Brand and generic

900 Generic Rx $30 for first 4 visits1 $900 $3,900 $122 Generic only

900 $30 for first 4 visits1 $900 $3,900 $147 Brand and generic

400 Generic Rx $30 for first 4 visits1 $400 $2,900 $152 Generic only

400 $30 for first 4 visits1 $400 $2,900 $178 Brand and generic

Balance plans* 2500 $30 $2,500 $7,500 $133 Brand and generic

1700 $30 $1,700 $6,500 $158 Brand and generic

1000 $30 $1,000 $5,500 $180 Brand and generic

Shield Savings* 5200 $0 after deductible $5,200 $5,200 $84 Brand and generic

3500 $0 after deductible $3,500 $5,000 $98 Brand and generic

4000/8000 $0 after deductible $4,000 $4,000 $96 Brand and generic

1800/3600 $35 after deductible $1,800 $5,950 $113 Brand and generic

Active Start* 35 Generic Rx $35 $0 $7,500 $180 Generic only

35 $35 $0 $7,500 $237 Brand and generic

25 Generic Rx $25 $0 $6,000 $219 Generic only

25 $25 $0 $6,000 $257 Brand and generic

Essential packages* 4500 $40 for first 3 visits1 $4,500 $4,500 $137 Generic only

3000 $40 for first 3 visits1 $3,000 $3,000 $182 Generic only

1750 $40 for first 3 visits1 $1,750 $1,750 $229 Generic only

Shield Spectrum PPO 5500 35% after deductible $5,500 $7,500 $163 Brand and generic

5000* $35 after deductible $5,000 $7,000 $128 Brand and generic

HMO plans Access+ Value $35 $2,000 $4,000 $474 Brand and generic

Access+ $20 $2,000 $3,000 $585 Brand and generic

Please note: Annual deductibles and copayment/coinsurance/out-of-pocket maximums listed in this chart are for individuals. Copayments and coinsurance amounts are for services received from participating providers. Office visits are not subject to deductible unless noted.

* Vital Shield plans, Vital Shield Plus plans, Active Start plans, Essential packages, Balance plans, Shield Savings plans, and Shield Spectrum PPO 5000 are underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Plans may be subject to regulatory approval.

1 Visit limits are per member per calendar year before deductible or copayment/coinsurance maximum. Subsequent visits may be subject to the deductible or copayment/coinsurance maximum. See each plan’s Policy for details.

2 For certain plans, copayments for some services do not count toward the copayment/coinsurance maximum. The copayment/coinsurance/out-of-pocket maximums in this chart include the plan deductible.

3 RatesareeffectiveMarch2012forindividualsage19to29.RatesapplytoSantaBarbaraCountyfor:VitalShieldplans,VitalShieldPlus2900GenericRx,Essential1750package,and Shield Savings 3500 plans; parts of Orange County for: Active Start plans, Shield Spectrum PPO plans, Balance plans, Essential 3000 package, Essential 4500 package, VitalShieldPlus400,VitalShieldPlus400GenericRx,ShieldSavings1800/3600,andShieldSavings5200plans;ContraCostaCountfor:VitalShieldPlus900,VitalShieldPlus900GenericRx,VitalShieldPlus2900,andShieldSavings4000/8000;partsofLosAngelesCountyfor:Access+HMOpackageandAccess+ValueHMO.Ratesmayvaryandareforpeople in good health.


Dental plans, dental + vision, and term life insurance coverage

Dental and dental + vision coverageComplete your Blue Shield health coverage with affordable and comprehensive dental plans.Did you know that more than 90% of all common diseases have oral symptoms?1 And studies have shown that periodontal (gum) disease is linked to other serious health risks such as heart disease, stroke, and diabetes.2 Did you also know that eye disease and visual impairment are among the 10 most common causes of disability.3 When some diseases are diagnosed early, treatment can be more successful, and in turn reduce your overall cost of health.

Blue Shield offers a range of affordable HMO and PPO dental plans to fit your dental needs, and complement your Blue Shield health plan. In addition, we now offer a dental and vision plan package − Specialty DuoSM,4 − that includes comprehensive dental and vision coverage to give you the extra protection that your teeth and eyes deserve. And when purchased together, Blue Shield can be your single-source provider for medical and dental, or medical and dental + vision coverage.

Blue Shield’s Specialty Duo4 dental + vision package and dental plans are offered with or independent of Blue Shield medical plans and are available to people of all ages living in California.5 Further details are provided in the benefit section of this booklet.

Blue Shield Specialty Duo dental + vision package highlightsSpecialty Duo package – Provides a full range of dental and vision protection including orthodontic benefits.

Specialty Duo dental network plan features:

•Accesstoover21,000generalandspecialtycareproviders in California6

•Twoannualteethcleanings,plusannualX-raysandoralcancer screening for $0 copayment

•Lowcopaymentsforminorrestorativeandmajorservices

•Fixedcopaymentswhenusingnetworkdentists

•Nowaitingperiodfordiagnosticorpreventiveservices

•Three-monthwaitingperiodforminorrestorativeservices(includes periodontics and endodontics services) and 12-month waiting period for major restorative and orthodontic services

•Orthodonticbenefitsforchildrenandadults

•$50calendar-yeardeductiblepermember

•$1,000calendar-yearbenefitmaximumpermember,ofwhich up to $500 per member, per year can be used for non-network benefits7

•Enhanceddentalbenefitsforpregnantwomen

Specialty Duo vision network plan features:

• Accesstoover5,900visioncareprovidersinCalifornia8

• Nocopaymentsforeyeexams• Choiceofnetworkornon-networkvisionproviders

for services• $25copaymentforlensesandlow-visionaids• $100frameallowancethatcanbeusedtowardany

pair of frames• Coverageforaneyeexamonceevery12months• Coverageforlensesorcontactlensesevery24months,

or 12 months with a prescription change• Coverageforframesevery24months• 90-daywaitingperiodforservices• Benefitsfornon-prescriptionsunglassesifyou’vehad

LASIKorPRKsurgery


Blue Shield Dental plan highlightsPPO – Blue Shield’s PPO plans allow the freedom to choose any dental provider, in and out of network. Out-of-pocket costs for covered services are lowest when you receive care from the extensive network provider selection.

HMO – Choose a provider from our dental HMO provider network for all of your family’s dental care.

Dental PPO – Provides extensive protection including orthodontic benefits.

Value SmileSM PPO4 – Provides preventive, diagnostic dental care, plus some minor restorative services; designed to aid in reduction of future costly services.

Dental HMO – Provides a full range of dental benefits with fixed member copayments.

Network plan features:

•Accesstoover21,000generalandspecialty care providers in California6

•Twoannualteethcleanings,plusannualX-rays and oral cancer screening for $0 copayment

•Lowcopaymentsforminorrestorativeand major services

•Fixedcopaymentswhenusing network dentists

•Nowaitingperiodfordiagnosticorpreventive services

•Three-monthwaitingperiodforminorrestorative services (includes periodontics and endodontics services) and 12-month waiting period for major restorative and orthodontic services

•Orthodonticbenefitsforchildren and adults

•$50calendar-yeardeductible per member

•$1,000calendar-yearbenefitmaximumper member, of which up to $500 per member, per year can be used for non-network benefits7

•Enhanceddentalbenefitsfor pregnant women


•Accesstoover21,000generalandspecialty care providers in California6

•Twoannualteethcleanings,plusannualX-rays and oral cancer screening for $0 copayment

•Lowcopaymentsforminorservices

•Nocoverageformajorservices

•Fixedcopaymentswhenusing network dentists

•Nowaitingperiods

•$25calendar-yeardeductible per member

•$500calendar-yearbenefitmaximumper member7

•Enhanceddentalbenefitsfor pregnant women


•Accesstoover9,000dentalproviderlocations in California6

•Twoannualteethcleanings,plusannualX-rays for $0 copayment

•Low,fixedcopaymentsforminorrestorative and major services

•Nowaitingperiodswithexceptionoforthodontics, which has a 12-month waiting period

•Orthodonticbenefitsforchildren and adults

•Nodeductiblesorcalendar-yearmaximums

•Specialtycareservicesavailable with referral from your primary dental provider

1 “Prevent Oral Health Problems: Visit a Dentist Twice a Year”; Academy of General Dentistry, January 2007.

2 “Mouth - Body Connection,” American Academy of Periodontology website: www.perio.org/consumer/mbc.top2.htm.

3 “VisionImpairmentandAccesstoEyeCare,”BehaviorRiskFactorSurveillanceSystem,NewYorkStateDepartmentofHealth,Spring2008.

4 Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Pending regulatory approval.

5 To be eligible for a dental plan, you must be a California resident at the time of enrollment. Benefits are only available within the state of California, except in emergency situations. If you had a Blue Shield individual and family dental plan or dental + vision package cancelled, you must wait six months from the date of cancellation before you can reapply.

6 Dental providers in California are available through the contracted dental plan administrator.

7 Each calendar year, the member is responsible for all charges incurred after the plan has paid these amounts for covered dental services.

8 Vision providers in California are available through the contracted vision plan administrator.

PLEASE NOTE:

Value Smile PPO, Dental PPO, and Dental HMO plan benefits supersede the Access+ HMO® Dental Plan and EssentialSM Dental PPO Plan dental benefits. If you’re an Access+ HMO or Essential package plan member, and you purchase a Dental PPO, Dental HMO, or Value Smile PPO dental plan, you will receive the benefits of the Value Smile PPO, Dental PPO, or Dental HMO plan you have chosen, and will not receive any of the dental benefits of the Access+ HMO Dental Plan or Essential Dental PPO Plan.


Life insurance

Individual term life insurance* coverage

Facing financial burdens after the loss of a loved one can be overwhelming – having life insurance helps. Individual term life insurance plans from Blue Shield Life can help your family cover funeral expenses, as well as other daily living expenses. We offer the financial protection and security of $10,000, $30,000, $60,000, $90,000, or $100,000 in term life insurance. In addition, life insurance can be continued beyond the termination of your health plan when the life insurance policy has been in effect for six or more months.

Further benefit details are provided in the benefit section of this booklet.

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


How to apply

Once you select the health plan that is right for you, simply fill out an application. If you are submitting a paper application, use the following checklist to help ensure that your application is complete, so it can be processed as quickly as possible.

Have you and each applying family member answered every question on the application?

Have you signed all areas requesting signatures?

Are you returning the application within 30 days of the date you signed it?

If you are signing up for a Blue Shield HMO health plan, or HMO dental plan, have you chosen and listed a Personal Physician or dental provider for yourself and each family member on your application?

Did you include a personal check, money order, or credit card information for the first month of coverage?

Have you indicated your payment option?

To speed up the application process and ensure that your application is complete, ask your broker to send you a link to our online application system.

Interested in adding Specialty Duo,* Dental PPO, Value Smile PPO*, Dental HMO, or term life insurance* coverage to your health plan coverage? Simply complete the dental coverage or term life insurance part of the Blue Shield health plan application. When your health plan coverage is approved, your dental or term life insurance coverage effective dates will be the same as your health plan’s effective date.† Also, in most cases you’ll receive one bill that combines your health, dental, and, if applicable, life insurance dues/premiums.

If you choose to apply only for dental coverage, and not healthcare coverage, you can easily enroll by completing the dental-only application available at blueshieldca.com/dental.

* Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Pending regulatory approval.

† Assumes complete and accurate term life insurance replacement coverage information, if applicable, is received at time of health plan application. If you are replacing an existing term life insurance policy with a Blue Shield Life term life insurance policy, make sure you complete the Acknowledgement of Life Insurance Replacement Coverage form (C20272) and submit it along with your Blue Shield health plan application.


Health plan details

The following pages give you a closer look at the many benefits and services each plan offers you.

Please take your time reviewing all your options before you apply.

Vital Shield plans* – Valuable health coverage at an affordable price.

Vital Shield Plus plans* – All the benefits of Vital Shield plans, plus more!

Balance plans* – The right balance of solid coverage and lower rates.

Essential packages* – Provide three essential benefits – medical, dental, and vision – in one essential plan.

Shield Savings plans* – High-deductible health plans that are compatible with tax-advantaged Health Savings Accounts.

HMO plans – For those who like predictable out-of-pocket costs with minimal paperwork.

Shield Spectrum PPO plans–Robustplansofferingawiderangeofcoverage at predictable costs.

Active Start plans* – A blend of lower costs and comprehensive benefits with no medical deductibles.

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


Protect yourself with our lowest-priced PPO plans for individuals.

Is a Vital Shield plan right for you?Vital ShieldSM plans cover you with basic benefits and a low or moderate deductible in case of hospitalization, surgery, or other major medical events. Even before you have to meet the deductible, these lower-priced PPO options cover preventive care, one office visit, and generic prescription drugs. They are available for individuals only and offer only the most popular benefits, so you don’t pay for services you don’t expect to use, such as maternity care or brand-name prescription drug benefits.

Vital Shield advantages

Choice of low or moderate annual deductible ($900 or $2,900).

Most in-network benefits are covered at 100% after you meet the copayment maximum.

Preventive care at no additional cost.

Low copayments for generic prescription drugs at network pharmacies ($10).

One office visit each calendar year before you have to meet the deductible.

X-ray and laboratory outpatient services are $0 with preferred providers once you meet the plan’s copayment/coinsurance maximum.

Vital Shield plansUnderwritten by Blue Shield of California Life & Health Insurance Company.

Vital Shield 900

Vital Shield 2900


Vital Shield 900 Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $900 per individual Calendar Year Copayment Maximum

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

$4,900 per individual


Lifetime Benefit Maximum None Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 PROFESSIONAL SERVICES Professional (Physician) Benefits

Physician and specialist office visits (First visit per Calendar Year is covered prior to meeting the Copayment Maximum – subsequent visits are subject to the Copayment Maximum)

$402,3,4 $0 after copay maximum4

Subsequent physician and specialist office visits $0 after copay maximum2,4 $0 after copay maximum4 Other outpatient X-ray, pathology, and laboratory

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

$0 after copay maximum4 $0 after copay maximum4

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


Preventive Health Benefits Preventive Health Services

(see the description of Preventive Health Services in the definitions section of the Policy for more information)

$03 Not covered

OUTPATIENT SERVICES Outpatient surgery in a hospital 40% 50%5,6 Outpatient surgery performed at an Ambulatory

Surgery Center 40% 50%5,7

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

40% 50%6

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


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

40% 50%5,6

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


HOSPITALIZATION SERVICES

Inpatient Physician Services 40% 50% Inpatient Non-emergency Facility Services

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

40% 50%5,6


40% 50%5,6

EMERGENCY HEALTH COVERAGE Emergency room Services not resulting in admission

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

$100 per visit + 40%


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

40% 40%

Emergency room Physician Services 40% 40% AMBULANCE SERVICES

Emergency or authorized transport (surface or air) 40% 40%

Vital Shield 900

Covered Services Member Copayments


Covered Services Member Copayments PRESCRIPTION DRUG COVERAGE9,10 Participating Pharmacy Retail prescriptions (up to a 30-day supply)

Formulary Generic Drugs $10 per prescription3,11 Formulary Brand Name Drugs Not covered Non-Formulary Brand Name Drugs Not covered

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20 per prescription3,11 Formulary Brand Name Drugs Not covered Non-Formulary Brand Name Drugs Not covered

Specialty Pharmacies (up to a 30-day supply) Home Self-Administered Injectables 40%11

Preferred Providers1 Non-preferred Providers1 PROSTHETICS/ORTHOTICS

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

Not covered Not covered

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


DURABLE MEDICAL EQUIPMENT Durable Medical Equipment Not covered Not covered

MENTAL HEALTH SERVICES (PSYCHIATRIC)12 Inpatient Hospital Services 40% 50%5,6 Outpatient visits for severe mental health conditions 40% 50%5,6 Outpatient visits for non-severe mental health

conditions13 Not covered Not covered

CHEMICAL DEPENDENCY SERVICES12 (SUBSTANCE ABUSE) Inpatient Hospital Services for medical acute

detoxification 40% 50%5,6

Outpatient visits13 Not covered Not covered HOME HEALTH SERVICES

Home health care agency Services (up to 90 prior authorized visits per Calendar Year)

$0 after copay maximum4 Not covered

OTHER Pregnancy and Maternity Care Benefits

Prenatal and postnatal Physician office visits Not covered Not covered All necessary Inpatient Hospital Services for normal

delivery and Cesarean section Not covered Not covered

Family Planning Benefits Counseling and consulting $0 after copay maximum4 Not covered Tubal ligation $0 after copay maximum4 Not covered Vasectomy $0 after copay maximum4 Not covered Elective abortion $0 after copay maximum4 Not covered

Rehabilitation Benefits Office location Not covered Not covered

Chiropractic Benefits Chiropractic Services Not covered Not covered

Acupuncture Benefits Acupuncture Not covered Not covered

Care Outside of Plan Service Area (Benefits provided through the BlueCard® Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider)

Within US: BlueCard Program See Applicable Benefit See Applicable Benefit Outside of US: BlueCard Worldwide See Applicable Benefit See Applicable Benefit

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



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

2 Member has one visit per calendar year before the calendar year copayment/coinsurance maximum is met. After the one visit is used, the member pays 100% of the allowable amount until the calendar year copayment/coinsurance maximum is met, with no accrual to deductible or copayment/coinsurance maximum. Subsequent visits are $0 after the copayment/coinsurance maximum is reached.

3 Benefit is available prior to meeting any deductible. 4 These copayments do not count toward the medical deductible or copayment/coinsurance maximum, but will not be charged once the

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

copayment/coinsurance maximum is reached. See Policy for details. 6 For non-emergency hospital services and supplies received from a non-preferred hospital, Blue Shield’s payment is limited to $250 per

day. Members are responsible for all charges that exceed $250 per day. 7 Participating ambulatory surgery centers may not be available in all areas. Regardless of their availability, you can obtain outpatient

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

8 Bariatric surgery is covered when pre-authorized by the Plan. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties (“Designated Counties”), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Policy for further benefit details.

9 Brand-name prescription drugs are not covered with the exception of covered drugs and supplies for diabetes. Brand and generic diabetes medications/supplies are covered, and may be subject to Prior Authorization for medical necessity. See Policy for details.

10 This plan’s prescription drug coverage provides less coverage on average than the standard benefit set by the federal government for Medicare Part D (also called non-creditable coverage). It is important to know that generally you may only enroll in a Medicare Part D plan from October 15th through December 7th of each year. If you do not enroll in a Medicare Part D plan when you are first eligible to join, you may be subject to a late enrollment penalty in addition to your Part D premium when you enroll at a later date. For more information about your current plan’s prescription drug coverage, call the Customer Service telephone number on your identification card, Monday through Thursday between 8:00 a.m. and 5:00 p.m. or on Friday between 9:00 a.m. and 5:00 p.m. The hearing impaired may call the TTY number at (888) 239-6482.

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

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

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


Vital Shield 2900 Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $2,900 per individual Calendar Year Copayment Maximum





Physician and specialist office visits (First visit per Calendar Year is covered prior to meeting the Copayment Maximum – subsequent visits are subject to the Copayment Maximum)


Subsequent physician and specialist office visits $0 after copay maximum2,4 $0 after copay maximum4 Other outpatient X-ray, pathology, and laboratory

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





(see the description of Preventive Health Services in the definitions section of the Policy for more information)

$03 Not covered

OUTPATIENT SERVICES Outpatient surgery in a hospital 40% 50%5,6 Outpatient surgery performed at an Ambulatory

Surgery Center 40% 50%5,7


40% 50%6




40% 50%5,6



HOSPITALIZATION SERVICES

Inpatient Physician Services 40% 50% Inpatient Non-emergency Facility Services

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

40% 50%5,6


40% 50%5,6






40% 40%



Vital Shield 2900













MENTAL HEALTH SERVICES (PSYCHIATRIC)12 Inpatient Hospital Services 40% 50%5,6 Outpatient visits for severe mental health conditions 40% 50%5,6 Outpatient visits for non-severe mental health

conditions13 Not covered Not covered

CHEMICAL DEPENDENCY SERVICES12 (SUBSTANCE ABUSE) Inpatient Hospital Services for medical acute

detoxification 40% 50%5,6





Prenatal and postnatal Physician office visits Not covered Not covered All necessary Inpatient Hospital Services for normal

delivery and Cesarean section Not covered Not covered











2 Member has one visit per calendar year before the calendar year copayment/coinsurance maximum is met. After the one visit is used, the member pays 100% of the allowable amount until the calendar year copayment/coinsurance maximum is met, with no accrual to deductible or copayment/coinsurance maximum. Subsequent visits are $0 after the copayment/coinsurance maximum is reached.


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











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

Is a Vital Shield Plus plan right for you?You want the same coverage as our Vital Shield plans, plus more covered office visits in a calendar year, plus a lower deductible option, plus brand or generic prescription drug options, plus lower office visit copayments. Vital ShieldSM Plus plans offer you and your family the vital health coverage you need to protect yourself against the high costs of hospitalization, surgery, and other major medical events. And with no maternity coverage, and generic-only prescription drug coverage options, you aren’t paying for services you don’t expect to use.

Vital Shield Plus advantages

Control your monthly rate by choosing a low annual deductible of $400, a moderate deductible of $900, or a higher deductible of $2,900.

Four office visits each calendar year before you have to meet the deductible, so you will get the care you need in case of illness.

$10 generic prescription drug coverage right away, before you have to meet a deductible, at network pharmacies.

Most benefits are covered at 100% after you meet the copayment/coinsurance maximum, so you’re protected when you need it most.


Outpatient X-ray and laboratory services accrue to the copayment/coinsurance maximum when using preferred providers, and are $0 with preferred providers once you meet the plan’s copayment maximum.

If you do not meet your annual deductible in a calendar year, you can “carry over” the amount accrued, from October to December of that year, and apply it toward your annual medical deductible for the following year.

Vital Shield Plus 400

VitalShieldPlus400GenericRx





Vital Shield Plus plans provide you with more than the basics, and give you the option of purchasing generic-only or brand-name prescription drug coverage, for lower monthly rates.


Vital Shield Plus 400 Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible2 $400 per individual / $800

per family $5,000 per individual /

$10,000 per family (excludes Preferred Provider deductible)

Calendar Year Copayment Maximum

(Includes the medical plan deductible) $2,900 per individual /

$5,800 per family $15,000 per individual /

$30,000 per family (excludes Preferred Provider

Copayment Maximum) Calendar Year Brand Name Drug Deductible $500 per individual n/a Lifetime Benefit Maximum None Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 PROFESSIONAL SERVICES Professional (Physician) Benefits

Physician and specialist office visits (First four visits per Calendar Year are covered prior to meeting the Copayment Maximum – subsequent visits are subject to the Copayment Maximum)


Subsequent physician and specialist office visits $0 after copay maximum3,5 $0 after copay maximum5 Other outpatient X-ray, pathology, and laboratory (Diagnostic testing by providers other than outpatient laboratory, pathology, and imaging departments of hospitals/facilities)




Preventive Health Benefits Preventive Health Services (see the description of Preventive Health Services in the definitions section of the Policy for more information)

$04 Not covered

OUTPATIENT SERVICES Outpatient surgery in a hospital 40% 50%7,8 Outpatient surgery performed at an Ambulatory Surgery Center

40% 50%7,9


40% 50%8




40% 50%7,8



HOSPITALIZATION SERVICES Inpatient Physician Services 40% 50% Inpatient Non-emergency Facility Services (Semi-private room and board, and medically-necessary Services and supplies, including Subacute Care)

40% 50%7,8


40% 50%7,8

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

$100 per visit + 40% $100 per visit + 40%


40% 40%




Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1


Emergency or authorized transport (surface or air) 40% 40% PRESCRIPTION DRUG COVERAGE11 Participating Pharmacy Retail prescriptions (up to a 30-day supply)

Formulary Generic Drugs $10 per prescription4,12 Formulary Brand Name Drugs $45 per prescription12,13 Non-Formulary Brand Name Drugs Not covered

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20 per prescription4,12 Formulary Brand Name Drugs $90 per prescription12,13 Non-Formulary Brand Name Drugs Not covered

Specialty Pharmacies (up to a 30-day supply) Home Self-Administered Injectables 40%12,13







MENTAL HEALTH SERVICES (PSYCHIATRIC)14 Inpatient Hospital Services 40% 50%7,8 Outpatient visits for severe mental health conditions 40% 50%7,8 Outpatient visits for non-severe mental health conditions15


CHEMICAL DEPENDENCY SERVICES14 (SUBSTANCE ABUSE) Inpatient Hospital Services for medical acute detoxification

40% 50%7,8





Prenatal and postnatal Physician office visits Not covered Not covered All necessary Inpatient Hospital Services for normal delivery and Cesarean section












2 If the annual plan deductible has not been met, any charges that accumulate towards the plan deductible in the last three months of the calendar year will be credited towards the plan deductible for the following calendar year.

3 Member has four visits per calendar year before the calendar year copayment/coinsurance maximum is met. After the four visits are used, the member pays 100% of the allowable amount until the calendar year copayment/coinsurance maximum is met, with no accrual to deductible or copayment/coinsurance maximum. Subsequent visits are $0 after the copayment/coinsurance maximum is reached.


copayment/coinsurance maximum is reached. See Policy for details. 6 These copayments do not count toward the medical deductible, but do count toward the copayment/coinsurance maximum, and will

not be charged once the copayment/coinsurance maximum is reached. See Policy for details. 7 These copayments do not count toward the copayment/coinsurance maximum. They will continue to be charged once the





11 This plan’s prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called creditable coverage). Because this plan’s prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Medicare Part D premium.


13 If a member requests a brand-name prescription drug or the physician indicates “dispense as written” (DAW) for a prescription, when an equivalent generic drug is available, and the brand-name drug deductible has been satisfied, the member pays the generic copayment plus the cost difference between the brand and generic drug. See Policy for details.



Vital Shield Plus 400 Generic Rx


Vital Shield Plus 400 Generic Rx Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible2 $400 per individual / $800






$30,000 per family (excludes Preferred Provider Copayment

Maximum) Lifetime Benefit Maximum None Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 PROFESSIONAL SERVICES Professional (Physician) Benefits








$04 Not covered


40% 50%7,9


40% 50%8




40% 50%7,8




40% 50%7,8


40% 50%7,8




40% 40%






Emergency or authorized transport (surface or air) 40% 40% PRESCRIPTION DRUG COVERAGE11,12 Participating Pharmacy Retail prescriptions (up to a 30-day supply)




Preferred providers1 Non-preferred Providers1 PROSTHETICS/ORTHOTICS

Prosthetic equipment and devices Separate office visit copay may apply)








40% 50%7,8
































Vital Shield Plus 900 Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible2 $900 per individual / $1,800







Copayment Maximum) Calendar Year Brand Name Drug Deductible $500 per individual Not covered Lifetime Benefit Maximum None Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 PROFESSIONAL SERVICES Professional (Physician) Benefits








$04 Not covered


40% 50%7,9


40% 50%8




40% 50%7,8




40% 50%7,8


40% 50%7,8




40% 40%



















40% 50%7,8
































Vital Shield Plus 900 Generic Rx Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible2 $900 per individual / $1,800







Copayment Maximum) Lifetime Benefit Maximum None Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 PROFESSIONAL SERVICES Professional (Physician) Benefits








$04 Not covered


40% 50%7,9


40% 50%8




40% 50%7,8




40% 50%7,8


40% 50%7,8




40% 40%

Emergency room Physician Services 40% 40%




Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 AMBULANCE SERVICES














40% 50%7,8
































Vital Shield Plus 2900 Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible2 $2,900 per individual /







Copayment Maximum) Calendar Year Brand Name Drug Deductible $500 per individual Not covered Lifetime Benefit Maximum None Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 PROFESSIONAL SERVICES Professional (Physician) Benefits








$04 Not covered


40% 50%7,9


40% 50%8




40% 50%7,8




40% 50%7,8


40% 50%7,8




40% 40%



















40% 50%7,8
































Vital Shield Plus 2900 Generic Rx Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible2 $2,900 per individual /







Copayment Maximum) Lifetime Benefit Maximum None Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 PROFESSIONAL SERVICES Professional (Physician) Benefits








$04 Not covered


40% 50%7,9


40% 50%8




40% 50%7,8




40% 50%7,8


40% 50%7,8




40% 40%



















40% 50%7,8
































These PPO plans offer a sensible balance of comprehensive benefits with relatively low deductibles.

Is a Balance plan right for you?You have a family and want the balance of solid coverage with a relatively low deductible and rates. BalanceSM plans provide coverage for preventive care, doctor’s office visits, generic prescription drug coverage, and emergency room care right away, before you meet your deductible. Additionally, they offer easy access to chiropractic care and acupuncture, and a wide range of other quality benefits. All Balance plans feature the same copayments, so you can choose which deductible amount best suits your needs.

Balance plan advantages

A variety of deductibles to choose from.

The plan’s copayment/coinsurance maximum includes your medical deductible, so you’ll pay only up to the copayment/coinsurance maximum in a calendar year for most services.

Doctor’s office visits are provided for a fixed copayment ($30) before you need to meet the deductible.

Generic prescription drugs for $10, and brand-name prescription drug coverage, too.


Includes benefits for chiropractic care and acupuncture.

Balance plansUnderwritten by Blue Shield of California Life & Health Insurance Company.

Balance Plan 1000

Balance Plan 1700

Balance Plan 2500


Balance Plan 1000 Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $1,000 per individual / $2,000 per family Calendar Year Copayment Maximum


$5,500 per individual / $11,000 per family


Calendar Year Brand Name Drug Deductible $500 per individual Not covered Lifetime Benefit Maximum None Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 PROFESSIONAL SERVICES Professional (Physician) Benefits

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

30% 50%


30% 50%


$02 Not covered

OUTPATIENT SERVICES Outpatient surgery in a hospital $250 per visit + 30% 50%4,5 Outpatient surgery performed at an Ambulatory Surgery Center

30% 50%4,6


30% 50%4,5


30% 50%


30% 50%4,5


30% 50%


30% 50%4,5


30% 50%4,5


$100 per visit + 30%2,8 $100 per visit + 30%2.8


30%2

30%2



Balance Plan 1000



Covered Services Member Copayments PRESCRIPTION DRUG COVERAGE9 Participating Pharmacy Retail prescriptions (up to a 30-day supply)

Formulary Generic Drugs $10 per prescription2,3 Formulary Brand Name Drugs $35 per prescription3,10 Non-Formulary Brand Name Drugs $50 or 50% (whichever is

greater) per prescription3,10 Mail Service Prescriptions (up to a 60-day supply)


greater) per prescription3,10 Specialty Pharmacies (up to a 30-day supply)

Home Self-Administered Injectables 30% of negotiated rate3,10 Preferred providers1 Non-preferred Providers1 PROSTHETICS/ORTHOTICS


30% 50%


30% 50%

DURABLE MEDICAL EQUIPMENT Durable Medical Equipment 30% 50%

MENTAL HEALTH SERVICES (PSYCHIATRIC)11 Inpatient Hospital Services 30% 50%4,5 Outpatient visits for severe mental health conditions $302,3 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with Outpatient chemical dependency visits)12

30% Not covered


30% 50%4,5

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

30% Not covered

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

30% Not covered




Family Planning Benefits Counseling and consulting 30% Not covered Tubal ligation 30% Not covered Vasectomy 30% Not covered Elective abortion 30% Not covered

Rehabilitation Benefits Office location (up to 20 visits per Calendar Year; visit limit combines Outpatient Physical, Occupational, Respiratory, and Speech Therapy Services)

30% 50%

Chiropractic Benefits Chiropractic Services (up to 15 visits per Calendar Year; visit limit combines Outpatient acupuncture and chiropractic Services)

50%

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

Not covered

Acupuncture Benefits Acupuncture (up to 15 visits per Calendar Year; visit limit combines Outpatient acupuncture and chiropractic Services)

50% (Blue Shield’s payment is

limited to $25 per visit)


limited to $25 per visit) Care Outside of Plan Service Area (Benefits provided through the BlueCard® Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider)






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

once the copayment/coinsurance maximum is reached. See Policy for details. 4 These copayments do not count toward the copayment/coinsurance maximum. They will continue to be charged once the





8 These copayments do not count toward the medical deductible, but do count toward the copayment/coinsurance maximum, and will not be charged once the copayment/coinsurance maximum is reached. See Policy for details.












30% 50%


30% 50%


$02 Not covered


30% 50%4,6


30% 50%4,5


30% 50%


30% 50%4,5


30% 50%


30% 50%4,5


30% 50%4,5




30%2

30%2



Balance Plan 1700










30% 50%


30% 50%



30% Not covered


30% 50%4,5


30% Not covered


30% Not covered






30% 50%


50%


Not covered





























30% 50%


30% 50%


$02 Not covered


30% 50%4,6


30% 50%4,5


30% 50%


30% 50%4,5


30% 50%


30% 50%4,5


30% 50%4,5




30%2

30%2



Balance Plan 2500










30% 50%


30% 50%



30% Not covered


30% 50%4,5


30% Not covered


30% Not covered






30% 50%


50%


Not covered























Shield SavingsSM advantages

Your out-of-pocket maximum includes your plan deductible, so you’ll pay only up to your plan’s out-of-pocket maximum in a calendar year.

No copayment for covered prescription drugs once you meet the out-of-pocket maximum, and convenient access to a mail service pharmacy benefit.


For Shield Savings plans 1800/3600 and 4000/8000: Once the family deductible is met, all remaining covered family members will have met their deductible. The family deductible can be met by any family member or combination of family members.

For Shield Savings plans 3500 and 5200: When two or more family members are on one plan, each covered individual has his or her own individual deductible, in case only one person needs expensive medical care.

Compatible with Health Savings Accounts.

A variety of deductible options.

Shield Savings plans 3500, 4000/8000, and 5200 provide critical services like office visits, hospitalizations, and outpatient X-ray and laboratory services with preferred providers for $0 after you meet the plan’s deductible.

A Health Savings Account (HSA) adds value to your plan

What is an HSA?

An HSA is a personal savings or investment account that you can combine with a high-deductible health plan. It may allow you to contribute tax-deductible money to a special savings account which you can use to pay for qualified medical expenses.

These high-deductible health plans offer preventive care before having to meet the deductible, are compatible with a Health Savings Account (HSA), and offer you protection against major healthcare expenses.

Shield Savings plansUnderwritten by Blue Shield of California Life & Health Insurance Company.

Shield Savings 1800/3600 (HSA)

Shield Savings 3500 (HSA)

Shield Savings 4000/8000 (HSA)

Shield Savings 5200 (HSA)


If you enroll in a Shield Savings plan and are qualified to open an HSA, you can use your tax-advantaged HSA funds to pay for qualified medical expenses, even those not covered by your health plan. These include dentist visits, eye exams, acupuncture, and more. You can also accumulate tax-advantaged funds for future healthcare funding needs such as long-term care.

If you don’t want an HSA, you can still choose a Shield Savings plan

TheseplansarePPOhealthplansandHSAparticipationisoptional.Regardlessofyoureligibility–nowor later – for an HSA, you can choose a Shield Savings plan for affordable rates, extensive coverage, and nationwide access to providers.

NOTICE: Blue Shield does not provide tax advice. HSAs are offered through financial institutions. If you intend to purchase this plan to use with an HSA for tax purposes, you should consult with your tax adviser about whether you are eligible and whether your HSA meets all legal requirements. Although we believethattheseplansmeettheselegalrequirements,theInternalRevenueServicehasnotruledonwhethertheplansarequalifiedashigh-deductiblehealthplans.IfyoupurchaseoneoftheseplanstoobtaintheincometaxbenefitsassociatedwithanHSAandtheInternalRevenueServicerulesthattheseplans do not qualify as high-deductible health plans, you may not be eligible for the income tax benefits associated with an HSA. In this instance, you may have adverse income tax consequences with respect to your HSA for all years in which you were not eligible. However, if there were such a ruling, or if government requirements for an HSA-eligible high-deductible health plan change, we intend to amend the Shield Savings plans, if necessary, to meet the requirements of a qualified plan. The plan’s monthly rates may also change as a result of a change in the plan(s).

Bridge Plan (hospital insurance indemnity rider option)*If you’re excited about the cost savings that an HSA-compatible high-deductible health plan offers, but concerned about saving up enough money to pay for your medical deductible should you be hospitalized in the first year, there’s no need to worry. With the Bridge Plan – offered exclusively with Shield Savings plans 3500, 4000/8000, and 5200 – you get the security and peace of mind of helping to supplement your health coverage, during your first year of funding a Health Savings Account (HSA), should you become hospitalized.

Here’s how it works: In the first 12 months of coverage, if you have an inpatient hospital stay of 72 hours or more, the benefit pays $1,500 per member. If more than one family member is covered, the benefit pays $1,500 per member, up to $3,000.†

Bridge Plan gives you the security of knowing that if something happens before you’ve built up funds in an HSA, you have a backup. The cost is only $60 for the year for an individual or $120 for a family, and to make it easy on your budget, the cost will be billed on a monthly basis. That means you pay only $5 per month for an individual or $10 per month for a family!

Bridge Plan benefitsIndemnity value Premium Eligibility for claim Term of coverage

Individual $1,500 per member per lifetime $60 for the year per individual contract 72 consecutive hours of

inpatient hospitalization

12 consecutive months starting from the 1st day the medical plan is effectiveFamily $1,500 per member per lifetime

up to $3,000 per family$120 for the year per family contract

Bridge Plan is available with the following eligible Blue Shield health plans: Shield Savings plans 3500, 4000/8000,‡ or 5200.

Bridge Plan:• CanonlybepurchasedatthetimeofapplicationforaneligibleBlueShieldhealthplan.

• Providescoverageduringthefirst12monthsofcoverageintheeligibleBlueShieldhealthplan and is not renewable.

• Pays$1,500permemberperlifetime(upto$3,000perfamily)foraninpatienthospitalstaylasting a minimum of 72 hours.

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

† The benefit is limited to $1,500 per member per lifetime and up to $3,000 per family. The rider is available only at time of enrollment in a qualifying Blue Shield health plan and provides coverage only during the first year of enrollment in the health plan. The premium due for the 12-month term of coverage will be billed to the member on a monthly or quarterly basis. Should the benefit be payable before the 12th month, or should the member terminate, change coverage, or otherwise no longer be eligible for this rider before the 12th month, the remaining balance will still be owed and must be paid. This rider is nonrefundable, so there is no premium refund – including a pro rata portion of premium – if the member terminates, changes coverage, or otherwise is no longer eligible for this rider.

‡ Bridge Plan is not available for purchase with the HIPAA guaranteed-issue version of Shield Savings 4000/8000.


Shield Savings 1800/3600 (HSA-Compatible) Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible2 (For family coverage, there is no individual deductible. All family members will receive benefits for covered services once the full family deductible has been satisfied by one, or any combination of family members.)

$1,800 for individuals / $3,600 for families3

Calendar Year Out-of-Pocket Maximum2

(Includes the medical plan deductible. Copayments for Preferred Providers accrue to both Preferred and Non-Preferred Provider Calendar Year Out-of-Pocket Maximum amounts.)

$5,950 for individuals / $11,900 for families



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

30% 50%


30% 50%


$04 Not covered

OUTPATIENT SERVICES Outpatient surgery in a hospital 30% 50%5 Outpatient surgery performed at an Ambulatory Surgery Center

30% 50%6


30% 50%5


30% 50%


30% 50%5


30% 50%


30% 50%5


30% 50%5




30% 30%



Shield Savings 1800/3600 (HSA-Compatible)




Formulary Generic Drugs $10 per prescription Formulary Brand Name Drugs $35 per prescription9 Non-Formulary Brand Name Drugs $50 or 50% (whichever is

greater) per prescription (maximum copayment of $150 per prescription)9

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20 per prescription Formulary Brand Name Drugs $70 per prescription9 Non-Formulary Brand Name Drugs $100 or 50% (whichever is


Specialty Pharmacies (up to a 30-day supply) Home Self-Administered Injectables 30% of negotiated rate9



30% 50%


30% 50%


MENTAL HEALTH SERVICES (PSYCHIATRIC)10 Inpatient Hospital Services 30% 50%5 Outpatient visits for severe mental health conditions $35 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)11

30% Not covered


30% 50%5

Outpatient visits (up to 20 visits per Calendar Year combined with outpatient non-severe mental health visits)11

30% Not covered


30% Not covered






30% 50%

Chiropractic Benefits Chiropractic Services (up to 12 visits per Calendar Year)



Not covered




Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 Care Outside of Plan Service Area (Benefits provided through the BlueCard® Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider)



1 Member is responsible for copayment in addition to any charges above allowable amounts. The coinsurance indicated is a percentage of allowable amounts. Preferred providers accept Blue Shield’s allowable amounts as full payment for covered services. Non-preferred providers can charge more than these amounts. When members use non-preferred providers, they must pay the applicable copayment plus any amount that exceed Blue Shield’s allowable amount. Charges in excess of the allowable amount do not count toward the calendar-year deductible or out-of-pocket maximum. Payments applied to your calendar year deductible accrue towards the out-of-pocket maximum.

2 The deductible and out-of-pocket maximum amounts may increase annually to reflect federal cost-of-living adjustments. 3 The family deductible is satisfied by any combination of family members; there's no individual deductible for families. 4 Benefit is available prior to meeting any deductible. 5 For non-emergency hospital services and supplies received from a non-preferred hospital, Blue Shield’s payment is limited to $300 per





9 If a member requests a brand-name prescription drug or the physician indicates “dispense as written” (DAW) for a prescription, when an equivalent generic drug is available, the member pays the generic copayment or contracted rate plus the cost difference between the brand and generic drug and it will not accrue to the deductible or out-of-pocket maximum. Some prescriptions will require prior authorization to obtain coverage (see formulary). Use of ID card is required to obtain prescriptions from the pharmacy or claim(s) will be denied. See Policy for details.





Shield Savings 3500 (HSA-Compatible) Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible (For family coverage, each individual will receive benefits for covered services once the individual deductible has been satisfied, and that amount will accumulate to the family deductible.)

$3,500 per individual / $7,000 per family2

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

Preferred Provider deductible)2 Calendar Year Out-of-Pocket Maximum (Includes the medical plan deductible)


$15,000 for individuals / $30,000 for families (excludes Preferred Provider Calendar Year

Out-of-Pocket Maximum) Lifetime Benefit Maximum None Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 PROFESSIONAL SERVICES Professional (Physician) Benefits

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

$0 after deductible 50%




$03 Not covered

OUTPATIENT SERVICES Outpatient surgery in a hospital $0 after deductible 50%4 Outpatient surgery performed at an Ambulatory Surgery Center

$0 after deductible 50%5









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





$100 per visit $100 per visit


$0 after deductible $0 after deductible

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

Emergency or authorized transport (surface or air) $0 after deductible $0 after deductible


Shield Savings 3500 (HSA-Compatible)



Formulary Generic Drugs $10 per prescription Formulary Brand Name Drugs $35 per prescription8 Non-Formulary Brand Name Drugs $50 or 50% (whichever is


Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20 per prescription Formulary Brand Name Drugs $70 per prescription8 Non-Formulary Brand Name Drugs $100 or 50% (whichever is

greater) per prescription (maximum copayment of

$300 per prescription) 30% of negotiated rate8







DURABLE MEDICAL EQUIPMENT Durable Medical Equipment $0 after deductible 50%

MENTAL HEALTH SERVICES (PSYCHIATRIC)9 Inpatient Hospital Services $0 after deductible 50%4 Outpatient visits for severe mental health conditions $0 after deductible 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)10

$0 after deductible Not covered










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

Rehabilitation Benefits Office location (up to 20 visits per Calendar Year; visit limit combines Outpatient chiropractic, Physical, Occupational, Respiratory, and Speech Therapy Services)

30% 50%

Chiropractic Benefits Chiropractic Services (up to 20 visits per Calendar Year; visit limit combines Outpatient chiropractic, Physical, Occupational, Respiratory, and Speech Therapy Services)



Not covered




Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 Care Outside of Plan Service Area (Benefits provided through the BlueCard® Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider)




2 Each family member only has to meet the per individual deductible, and that amount accumulates to the total family deductible. 3 Benefit is available prior to meeting any deductible. 4 For non-emergency hospital services and supplies received from a non-preferred hospital, Blue Shield’s payment is limited to $300 per





8 If a member requests a brand-name prescription drug or the physician indicates “dispense as written” (DAW) for a prescription, when an equivalent generic drug is available, the member pays the generic copayment or contracted rate plus the cost difference between the brand and generic drug and it will not accrue to the deductible or out-of-pocket maximum. Some prescriptions will require prior authorization to obtain coverage (see formulary). Use of ID card is required to obtain prescriptions from the pharmacy or claim(s) will be denied. See Policy for details.





Shield Savings 4000/8000 (HSA-Compatible) Underwritten by Blue Shield of California Life & Health Insurance Company. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS A SUMMARY ONLY. The POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible (For family coverage, there is no individual deductible. All family members will receive benefits for covered services once the full family deductible has been satisfied by one, or any combination of family members.)

$4,000 for individuals / $8,000 for families2

Calendar Year Out-of-Pocket Maximum (Includes the medical plan deductible. Copayments for Preferred Providers accrue to both Preferred and Non-Preferred Provider Calendar Year Out-of-Pocket Maximum amounts.)









$03 Not covered















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





Shield Savings 4000/8000 (HSA-Compatible)



Formulary Generic Drugs $0 after deductible Formulary Brand Name Drugs $0 after deductible8 Non-Formulary Brand Name Drugs $0 after deductible8

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $0 after deductible Formulary Brand Name Drugs $0 after deductible8 Non-Formulary Brand Name Drugs $0 after deductible8

Specialty Pharmacies (up to a 30-day supply) Home Self-Administered Injectables $0 after deductible8



















Rehabilitation Benefits Office location $0 after deductible 50%


$0 after deductible (Blue Shield’s payment is

limited to $25)

Not covered








2 The family deductible is satisfied by any combination of family members; there's no individual deductible for families. 3 Benefit is available prior to meeting any deductible. 4 For non-emergency hospital services and supplies received from a non-preferred hospital, Blue Shield’s payment is limited to $300 per





8 If a member requests a brand-name prescription drug or the physician indicates “dispense as written” (DAW) for a prescription, when an equivalent generic drug is available, the member pays the contracted rate plus the cost difference between the brand and generic drug and it will not accrue to the deductible or out-of-pocket maximum. Some prescriptions will require prior authorization to obtain coverage (see formulary). Use of ID card is required to obtain prescriptions from the pharmacy or claim(s) will be denied. See Policy for details.




Shield Savings 5200 (HSA-Compatible) Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval.

Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS A SUMMARY ONLY. The POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible (For family coverage, each individual will receive benefits for covered services once the individual deductible has been satisfied, and that amount will accumulate to the family deductible.)

$5,200 per individual / $10,400 per family2

$5,200 per individual / $10,400 per family (excludes

Preferred Provider deductible)2 Calendar Year Out-of-Pocket Maximum (Includes the medical plan deductible)


$15,000 for individuals / $30,000 for families (excludes Preferred Provider Calendar Year

Out-of-Pocket Maximum) Lifetime Benefit Maximum None

Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 PROFESSIONAL SERVICES Professional (Physician) Benefits






$03 Not covered















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





Shield Savings 5200 (HSA-Compatible)



Formulary Generic Drugs $0 after deductible Formulary Brand Name Drugs $0 after deductible8 Non-Formulary Brand Name Drugs $0 after deductible8

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $0 after deductible Formulary Brand Name Drugs $0 after deductible8 Non-Formulary Brand Name Drugs $0 after deductible8

Specialty Pharmacies (up to a 30-day supply) Home Self-Administered Injectables $0 after deductible8



















Rehabilitation Benefits Office location $0 after deductible 50%



limited to $25)

Not covered








2 Each family member only has to meet the per individual deductible, and that amount accumulates to the total family deductible. 3 Benefit is available prior to meeting any deductible. 4 For non-emergency hospital services and supplies received from a non-preferred hospital, Blue Shield’s payment is limited to $300 per





8 If a member requests a brand-name prescription drug or the physician indicates “dispense as written” (DAW) for a prescription, when an equivalent generic drug is available, the member pays the contracted rate plus the cost difference between the brand and generic drug and it will not accrue to the deductible or out-of-pocket maximum. Some prescriptions will require prior authorization to obtain coverage (see formulary). Use of ID card is required to obtain prescriptions from the pharmacy or claim(s) will be denied. See Policy for details.




Get value right away with our no-deductible Active Start PPO plans.

Is an Active Start plan right for you?Active StartSM plans feature a low generic prescription drug copayment and no annual deductible. These plans offer a blend of lower costs and comprehensive benefits for active individuals who want coverage in case of a serious medical event, but also want to take care of more routine day-to-day healthcare needs. The economical Active Start plans offer individual coverage only and do not provide maternity benefits.

Active Start plan advantages

Two plans with generic-only prescription drug coverage options to help save costs.

Low copayment for office visits ($25 or $35).

$10 copayments for generic prescription drugs at participating pharmacies with all plans.


Affordable coverage for individuals.

Benefits for chiropractic care and acupuncture.

Active Start plansUnderwritten by Blue Shield of California Life & Health Insurance Company.

Active Start Plan 25

Active Start Plan 25 GenericRx


Active Start Plan 35 GenericRx


Active Start Plan 25 Underwritten by Blue Shield of California Life & Health Insurance Company. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $0 Calendar Year Copayment Maximum

(Copayments for Preferred Providers accrue to both Preferred and Non-Preferred Provider Calendar Year Copayment Maximum amounts.)

$6,000 per individual $8,000 per individual



40% 50%


40% 50%


$0 Not covered

OUTPATIENT SERVICES Outpatient surgery in a hospital $500 per admit + 40% 50%2,3 Outpatient surgery performed at an Ambulatory Surgery Center

40% 50%2,4


40% 50%2,3


40% 50%


$500 per admit + 40% 50%2,3


40% 50%


$500 per admit + 40% 50%2,3


$500 per admit + 40% 50%2,3




40% 40%







Formulary Generic Drugs $10 per prescription2 Formulary Brand Name Drugs $35 per prescription2,7 Non-Formulary Brand Name Drugs $50 or 50% (whichever is






40% 50%


40% 50%


MENTAL HEALTH SERVICES (PSYCHIATRIC)8 Inpatient Hospital Services $500 per admit + 40% 50%2,3 Outpatient visits for severe mental health conditions $25 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)9

40%2 Not covered


$500 per admit + 40% 50%2,3


40%2 Not covered


40% Not covered






40% 50% (Blue Shield’s payment is limited to

$25 per visit) Chiropractic Benefits

Chiropractic Services (up to 12 visits per Calendar Year; visit limit combines Outpatient chiropractic, Physical, Occupational, Respiratory, and Speech Therapy Services)

40% Not covered

Acupuncture Benefits Acupuncture (up to 12 visits per Calendar Year)

50% (Blue Shield’s payment is limited to

$25 per visit)


$25 per visit) Care Outside of Plan Service Area (Benefits provided through the BlueCard® Program for out-of-state emergency and non-emergency care are provided at the preferred level of the local Blue Plan allowable amount when you use a Blue Cross/Blue Shield provider)






2 These copayments do not count toward the copayment/coinsurance maximum, and will continue to be charged once the copayment/coinsurance maximum is reached. See Policy for details.

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

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







Active Start Plan 25 Generic Rx Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $0 Calendar Year Copayment Maximum





40% 50%


40% 50%


$0 Not covered


40% 50%2,4


40% 50%2,3


40% 50%


$500 per admit + 40% 50%2,3


40% 50%


$500 per admit + 40% 50%2,3


$500 per admit + 40% 50%2,3




40% 40%



Active Start Plan 25 Generic Rx




Formulary Generic Drugs $10 per prescription2 Formulary Brand Name Drugs Not covered Non-Formulary Brand Name Drugs Not covered

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20 per prescription2 Formulary Brand Name Drugs Not covered Non-Formulary Brand Name Drugs Not covered




40% 50%


40% 50%



40%2 Not covered


$500 per admit + 40% 50%2,3


40%2 Not covered


40% Not covered









40% Not covered



$25 per visit)

















Active Start Plan 35 Underwritten by Blue Shield of California Life & Health Insurance Company. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $0 Calendar Year Copayment Maximum





40% 50%


40% 50%


$0 Not covered


40% 50%2,4


40% 50%2,3


40% 50%


$500 per admit + 40% 50%2,3


40% 50%


$500 per admit + 40% 50%2,3


$500 per admit + 40% 50%2,3




40% 40%













40% 50%


40% 50%



40%2 Not covered


$500 per admit + 40% 50%2,3


40%2 Not covered


40% Not covered









40% Not covered



$25 per visit)

















Active Start Plan 35 Generic Rx Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $0 Calendar Year Copayment Maximum





40% 50%


40% 50%


$0 Not covered


40% 50%2,4


40% 50%2,3


40% 50%


$500 per admit + 40% 50%2,3


40% 50%


$500 per admit + 40% 50%2,3


$500 per admit + 40% 50%2,3




40% 40%




Active Start Plan 35 Generic Rx



Formulary Generic Drugs $10 per prescription2 Formulary Brand Name Drugs Not covered Non-Formulary Brand Name Drugs Not covered

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20 per prescription2 Formulary Brand Name Drugs Not covered Non-Formulary Brand Name Drugs Not covered




40% 50%


40% 50%



40%2 Not covered


$500 per admit + 40% 50%2,3


40%2 Not covered


40% Not covered









40% Not covered



$25 per visit)

















Essential plans simplify getting the coverage you need by combining medical, dental, and vision benefits all in one package.

Is an Essential package right for you?You’re an individual who only wants coverage to protect you in case of major medical events, and also provides essential benefits for doctor visits. Our EssentialSM packages allow you to control the total annual amount you spend on copayments and deductibles, and include dental and vision coverage at no added cost. They are available for individuals only and offer essential benefits, so you don’t pay for services you don’t expect to use like maternity care or brand-name prescription drug benefits. By providing you with affordable coverage, including dental and vision, these plans offer you the essential coverage you need.

Essential advantages

Comprehensive coverage − includes medical, dental, and vision care.

Affordable monthly rates.

After you meet your deductible, you pay $0 for most covered services from preferred providers (see Policy for details).

Affordable copayments for generic prescription drugs at network pharmacies ($10).


Choice of three annual deductibles ($1,750, $3,000, and $4,500).

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

Essential 1750

Essential 3000

Essential 4500


Essential 1750 package Underwritten by Blue Shield of California Life & Health Insurance Company. Pending regulatory approval. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $1,750 per individual Calendar Year Copayment Maximum




Physician and specialist office visits (First three visits per Calendar Year are covered prior to meeting the deductible – subsequent visits are subject to the deductible)

$402,3 ($0 after deductible)

50%

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





$03 Not covered

OUTPATIENT SERVICES Outpatient surgery in a hospital $0 after deductible 50%4,5 Outpatient surgery performed at an Ambulatory Surgery Center



$0 after deductible 50%4,5












$100 per visit3,8

$100 per visit3,8





Essential 1750 package






Specialty Pharmacies (up to a 30-day supply) Home Self-Administered Injectables 30% of negotiated rate3,8







MENTAL HEALTH SERVICES (PSYCHIATRIC)11 Inpatient Hospital Services $0 after deductible 50%4,5 Outpatient visits for severe mental health conditions (First three visits per Calendar Year are covered prior to meeting the deductible – subsequent visits are subject to the deductible)

$402 ($0 after deductible)3 50%

Subsequent outpatient visits for severe mental health conditions

$0 after deductible2 50%

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











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









Essential Vision PPO Plan Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 Vision Services

Vision exam13 $53,8 $5 (and charges above the allowable amount)3,8

Essential Dental PPO Plan Covered Services Member Copayments Preferred Providers1 Non-preferred Providers1 Dental Benefits14

Preventive and diagnostic (including routine oral exams, X-rays, and teeth cleaning)

$015 Member reimbursed per procedure reimbursement

schedule Minor restorative (subject to $50 dental deductible, including amalgam and resin-based fillings)4

$35 - $100 (depending on procedure)15

Member reimbursed per procedure reimbursement

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



3 Benefit is available prior to meeting any deductible. 4 These copayments do not count toward the copayment/coinsurance maximum, and will continue to be charged once the







10 Brand-name prescriptions are not covered with the exception of covered drugs and supplies for diabetes. Brand and generic diabetes medications/supplies are covered, and may be subject to Prior Authorization for medical necessity. See Policy for details.



13 Vision exams are provided through a contracted vision plan administrator. 14 Dental benefits provided through the dental plan administrator. Benefits limited to $500 per calendar year combined. Three-month

waiting period following the effective date of coverage for minor restorative services. Calendar-year medical deductible does not apply to preventive dental services.

15 Blue Shield’s payment is limited to $500 per calendar year for Preventive, Diagnostic, and Minor Restorative. Member is responsible for all charges that exceed $500 per calendar year.



Essential Vision PPO Plan

Essential Dental PPO Plan


Essential 3000 package Underwritten by Blue Shield of California Life & Health Insurance Company. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $3,000 per individual Calendar Year Copayment Maximum






50%






$03 Not covered
















$100 per visit3,8

$100 per visit3,8







































































Essential 4500 package Underwritten by Blue Shield of California Life & Health Insurance Company. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $4,500 per individual Calendar Year Copayment Maximum






50%






$03 Not covered
















$100 per visit3,8

$100 per visit3,8







































































Shield Spectrum PPOs feature comprehensive coverage with rich benefits for families and individuals seeking a robust health plan.

Is a Shield Spectrum PPO right for you? Whether you are single or have a family, Shield Spectrum PPOSM plans will provide you with comprehensive coverage for doctor visits, prescription drugs, and hospital care. Shield Spectrum PPOs make it easy to visit the doctors and specialists you want with our large provider network. Keep in mind, when you receive care from Blue Shield PPO network providers, your out-of-pocket costs are always lower.

Shield Spectrum PPO advantages

Two deductible amounts to choose from: $5,000 or $5,500.

Includes generic and brand-name prescription drug coverage.

Generic prescription drug coverage for as low as $10, and you don’t need to meet a deductible.


When two or more family members are on one plan, each covered individual has his or her own individual deductible, in case only one person needs expensive medical care.

Copayment/coinsurance maximums help contain costs, because your family maximum is only twice the individual amount, no matter how many people are covered.

Shield Spectrum PPO

PPO 5000*

PPO 5500

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


Shield Spectrum PPO 5000 Underwritten by Blue Shield of California Life & Health Insurance Company. Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE POLICY FOR INDIVIDUALS AND FAMILIES SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $5,000 per individual / $10,000 per family Calendar Year Copayment Maximum






30% 50%


30% 50%


$02 Not covered


30% 50%3,5


30% 50%3,4


30% 50%


30% 50%3,4


30% 50%


30% 50%3,4


30% 50%3,4


30% 30%


30% 30%



Shield Spectrum PPO 5000










30% 50%


30% 50%


MENTAL HEALTH SERVICES (PSYCHIATRIC)10 Inpatient Hospital Services 30% 50%3,4 Outpatient visits for severe mental health conditions $35 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)11

30% Not covered


30% 50%3,4


30% Not covered


30% Not covered


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

30% 50%3,4


Rehabilitation Benefits Office location 30% 50%




















Shield Spectrum PPO 5500 Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Preferred Providers1 Non-preferred Providers1 Calendar Year Medical Deductible $5,500 per individual / $11,000 per family Calendar Year Copayment Maximum




Calendar Year Brand Name Drug Deductible $750 per individual Not covered


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

35% 50%


35% 50%

Preventive Health Benefits Preventive Health Services (see the description of Preventive Health Services in the definitions section of the Evidence of Coverage for more information)

$03 Not covered


35% 50%2,5


35% 50%2,4


35% 50%


35% 50%2,4


35% 50%

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

35% 50%2,4


35% 50%2,4




35% 35%




Shield Spectrum PPO 5500



Formulary Generic Drugs $10 per prescription3,8 Formulary Brand Name Drugs $45 per prescription8,9 Non-Formulary Brand Name Drugs $60 or 50%, whichever is

greater (Maximum copayment of $150 per

prescription)8,9 Mail Service Prescriptions (up to a 60-day supply)


greater) per prescription (Maximum copayment of $300 per prescription)8,9




35% 50%


35% 50%


MENTAL HEALTH SERVICES (PSYCHIATRIC)10 Inpatient hospital Services 35% 50%2,4 Outpatient visits for severe mental health conditions 35%2 50% Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)11

35% Not covered


35% 50%2,4


35% Not covered


35% Not covered


Prenatal and postnatal Physician office visits 35% 50% All necessary Inpatient Hospital Services for normal delivery and Cesarean section

35% 50%2,4


Rehabilitation Services Office location 35% 50%









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

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



6 Bariatric surgery is covered when pre-authorized by the Plan. However, for members residing in Imperial, Kern, Los Angeles, Orange, Riverside, San Bernardino, San Diego, Santa Barbara and Ventura counties (“Designated Counties”), bariatric surgery services are covered only when performed at designated contracting bariatric surgery facilities and by designated contracting surgeons; coverage is not available for bariatric services from any other preferred provider and there is no coverage for bariatric services from non-preferred providers. In addition, if prior authorized by the Plan, a member in a Designated County who is required to travel more than 50 miles to a designated bariatric surgery facility will be eligible for limited reimbursement for specified travel expenses for the member and one companion. Refer to the Evidence of Coverage for further benefit details.


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

9 If a member requests a brand-name prescription drug or the physician indicates “dispense as written” (DAW) for a prescription, when an equivalent generic drug is available, and the brand-name drug deductible has been satisfied, the member pays the generic copayment plus the cost difference between the brand and generic drug. See the EOC for details.




HMO plansOur HMO plans offer a predictable, cost-efficient way to manage your health care, especially if you or your dependents visit the doctor often. These plans may also help you to navigate the healthcare system.

Our HMO plans are perfect for those who like predictable out-of-pocket costs with minimal paperwork. Before having to meet a deductible, you’ll have easy access to a wide range of services for a small copayment, like doctor office visits and generic prescription drugs.

Access+ ValueSM HMO and Access+ HMO® plan advantages

Affordable $20/$35 office visit copayments.

$10 copayments for generic prescription drugs.


See a specialist in your Personal Physician’s participating medical group without a referral for a $35/$50 copayment.

Basic dental benefits included with the Access+ HMO package.

Practically no claim forms.

Personal care from your Personal PhysicianThe relationship you have with your Personal Physician is the key to your HMO plan.

He or she:

• Providesorcoordinatesallyournecessarymedicalservices;and

• Arrangesforreferralstospecialists,hospitals,andothercoverednon-physicianhealthcarepractitioners.

Special features

Direct access to specialists

With Access+ SpecialistSM you can go directly to a specialist or another physician in the same medical group or IPA as your Personal Physician, without a referral. When you do, depending on your plan, your copayment will be $35 or $50 per covered office visit. To use the Access+ Specialist option, you must belong to a medical group or IPA that is an Access+ Specialist provider group.

Direct access to gynecological exams and OB/GYN visits

Women can go directly to an OB/GYN or family practice physician in the same medical group or IPA as their Personal Physician for obstetrical/gynecological services, including annual exams, without a referral.

Money-back guaranteeOur member feedback program, Access+ Satisfaction,SM will refund your office-visit copayment if you are ever dissatisfied with the service you receive during a covered office visit with an HMO network physician. It will also provide a postage-paid postcard for your comments so you can share your valuable feedback with us.

Access+ Value HMO

Access+ HMO package


Access+ Value HMO Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS. Calendar Year Medical Deductible $2,000 per individual / $4,000 per family Calendar Year Copayment Maximum (Includes the medical plan deductible)


Calendar Year Brand Name Drug Deductible $400 Lifetime Benefit Maximum None Plan services and supplies are covered when performed, prescribed or authorized by your Personal Physician. Limitations and exclusions apply for certain services that are not obtained from or approved by your Personal Physician. See the EOC for details. Covered Services1 Member Copayments PROFESSIONAL SERVICES Professional (Physician) Benefits

Physician and specialist office visits $35 per visit2,3 Outpatient X-ray, pathology and laboratory $352,3

Access+ Specialist Benefits Office visit, Examination or Other Consultation

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


(see the description of Preventive Health Services in the definitions section of Evidence of Coverage for more information)

$02

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

Surgery Center6 $150 per visit


40% per visit2,3

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services)

Inpatient Physician Services $35 per visit2,3 Inpatient Non-emergency Facility Services

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

40% per admit



$150 per visit2,3

Emergency room Physician Services $35 per visit2,3 AMBULANCE SERVICES

Emergency or authorized transport (surface or air) $50 per trip2,3 PRESCRIPTION DRUG COVERAGE7,8 Participating Pharmacy Retail Prescriptions (up to a 30-day supply)

Formulary Generic Drugs $10/prescription2,4 Formulary Brand Name Drugs $35/prescription4,9

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20/prescription2,4 Formulary Brand Name Drugs $70/prescription4,9

Specialty Pharmacies (up to a 30-day supply) Home Self-Administered Injectables 20% of negotiated rate up to $100 maximum4,9

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

50%2,4


50%2,4

Access+ Value HMO

Covered Services1 Member Copayments


Covered Services1 Member Copayments DURABLE MEDICAL EQUIPMENT

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

50%2,4

MENTAL HEALTH SERVICES (PSYCHIATRIC)10 Inpatient Hospital Services 40% per admit Outpatient visits for severe mental health conditions $353 per visit ($504 per visit if provider is MHSA Access+

Specialist provider)2,5 Outpatient visits for non-severe mental health

conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)11

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

CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)10 Inpatient Hospital Services for medical acute

detoxification 40% per admit


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

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

OTHER Pregnancy and Maternity Care Benefits12

Prenatal and postnatal Physician office visits $35 per visit2,3 All necessary Inpatient Hospital Services for normal

delivery, Cesarean section, and complications of pregnancy

40% per admit

Family Planning Benefits Counseling and consulting $35 per visit2,3 Infertility Services Not covered Tubal ligation13 $100 per occurrence2,3 Elective abortion $100 per occurrence2,3 Vasectomy $75 per occurrence2,3

Rehabilitation Benefits Office location $35 per visit2,3

Chiropractic Benefits Chiropractic Services Not covered

Urgent Care Benefits (BlueCard® Program)14

Urgent Services outside your Personal Physician Service Area

$50 per visit2




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

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

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

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

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

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


8 Only medically necessary outpatient formulary drugs are covered, unless prior authorization is obtained from Blue Shield Pharmacy Services. Non-formulary drugs may be covered only if prior authorization is obtained from Blue Shield Pharmacy Services. After all necessary documentation is available from your Physician, prior authorization approval or denial will be provided to your Physician within two working days of the request. Member is then responsible for the brand prescription copayment. Please see the EOC for details.


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


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

13 The tubal ligation copayment does not apply when the procedure is performed in conjunction with delivery or abdominal surgery. 14 Authorization by Blue Shield is required for more than two out-of-area follow-up outpatient visits or for out-of-area follow-up care that

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


Access+ HMO package Uniform Health Plan Benefits and Coverage Matrix THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY ONLY. THE EVIDENCE OF COVERAGE SHOULD BE CONSULTED FOR A DETAILED DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.

Medical Benefits Calendar Year Medical Deductible $2,000 per individual / $4,000 per family Calendar Year Copayment Maximum (Includes the medical plan deductible)


Calendar Year Brand Name Drug Deductible $200 Lifetime Benefit Maximum None Plan services and supplies are covered when performed, prescribed or authorized by your Personal Physician. Limitations and exclusions apply for certain services that are not obtained from or approved by your Personal Physician. See the EOC for details. Covered Services1 Member Copayments PROFESSIONAL SERVICES Professional (Physician) Benefits

Physician and specialist office visits $20 per visit2,3 Outpatient X-ray, pathology and laboratory $202,3

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

$35 per visit2,4.,5

Preventive Health Benefits Preventive Health Services (see the description of Preventive Health Services in the definitions section of Evidence of Coverage for more information)

$02

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

$150 per visit


$35 per visit2,3

HOSPITALIZATION SERVICES Hospital Benefits (Facility Services)

Inpatient Physician Services $20 per visit2,3

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

$250 per admit


$75 per visit2,3

Emergency room Physician Services $20 per visit2,3 AMBULANCE SERVICES

Emergency or authorized transport (surface or air) $50 per trip2,3 PRESCRIPTION DRUG COVERAGE7,8 Participating Pharmacy Retail Prescriptions (up to a 30-day supply)

Generic drugs $10 per prescription2,4 Formulary brand-name drugs $35 per prescription4,9

Mail Service Prescriptions (up to a 60-day supply) Formulary Generic Drugs $20/prescription2,4 Formulary Brand Name Drugs $70/prescription4,9

Specialty Pharmacies (up to a 30-day supply) Home Self-Administered Injectables 20% of negotiated rate up to $100 maximum4,9


Access+ HMO package


Covered Services1 Member Copayments PROSTHETICS/ORTHOTICS


50%2,4


50%2,4

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

50%2,4

MENTAL HEALTH SERVICES (PSYCHIATRIC)10 Inpatient Hospital Services $250 per admit Outpatient visits for severe mental health conditions $203 per visit ($354 per visit if provider is MHSA Access+

Specialist provider)2,5 Outpatient visits for non-severe mental health conditions (up to 20 visits per Calendar Year combined with outpatient chemical dependency visits)11

$20 per visit ($35 per visit if provider is MHSA Access+ Specialist

provider)2,4,5 CHEMICAL DEPENDENCY SERVICES (SUBSTANCE ABUSE)10

Inpatient Hospital Services for medical acute detoxification

$250 per admit


$20 per visit ($35 per visit if provider is MHSA Access+ Specialist

provider)2,4,5 HOME HEALTH SERVICES

Home health care agency Services $202,3 OTHER Pregnancy and Maternity Care Benefits12

Prenatal and postnatal Physician office visits $20 per visit2,3 All necessary Inpatient Hospital Services for normal delivery, Cesarean section, and complications of pregnancy

$250 per admit

Family Planning Counseling and consulting $20 per visit2,3 Infertility Services Not covered Tubal ligation13 $100 per occurrence2,3 Elective abortion $100 per occurrence2,3 Vasectomy $75 per occurrence2,3

Rehabilitation Benefits Office location $20 per visit2,3

Chiropractic Benefits Chiropractic Services Not covered

Urgent Care Benefits (BlueCard® Program)14 Urgent Services outside your Personal Physician

Service Area $50 per visit2




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

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

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

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

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

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


8 Only medically necessary outpatient formulary drugs are covered, unless prior authorization is obtained from Blue Shield Pharmacy Services. Non-formulary drugs may be covered only if prior authorization is obtained from Blue Shield Pharmacy Services. After all necessary documentation is available from your Physician, prior authorization approval or denial will be provided to your Physician within two working days of the request. Member is then responsible for the brand prescription copayment. Please see the EOC for details.


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


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

13 The tubal ligation copayment does not apply when the procedure is performed in conjunction with delivery or abdominal surgery. 14 Authorization by Blue Shield is required for more than two out-of-area follow-up outpatient visits or for out-of-area follow-up care that

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


Access+ HMO Dental Plan benefits Calendar Year Deductible $0 Calendar Year Benefit Maximum None Covered Services1 Member Copayments Diagnostic services

Comprehensive oral exams $20 (Plus $10 for full-mouth Series X-rays)

Preventive Care Prophylaxis (cleanings, one every 6 months)

Adult $20 Child $20

Sealant/per tooth2 (covered to age 16) $10 Restorative services One-surface composite (filling)

80%3

Crown (porcelain fused to noble metal) 80%3 Endodontics

Anterior root canal 80%3 Molar root canal Not covered

Periodontics Osseous surgery/per quadrant Not covered Periodontal root planning/per quadrant 80%3

Prosthetics Bridge Pontic/False Tooth - High Noble Metal (per unit) 80%3 Bridge Retainer – Porcelain Fused to High Noble Metal (per unit)

80%3

Complete denture (upper or lower) 80%3 Oral surgery

Extraction (single tooth)

80%3

Removal of impacted tooth (complete bony) Not covered Services for pregnant women (not subject to plan deductibles with network dentists)

Not covered

Orthodontics Fully banded (two year) case – child Not covered Fully banded (two year) case – adult Not covered

Please Note: Diagnostic and preventive services are not subject to plan deductibles. Benefits are subject to modification for subsequently enacted state or federal legislation.

1 Services available only when you are enrolled in Access+ HMO Dental Plan. (Access+ dentists are listed in the Blue Shield Directory of Access+ Dentists.)

2 Coverage for sealants is limited to the first and second permanent molars. 3 Based on the attending dentist’s billed charges.


Access+ HMO Dental Plan benefits


Individual term life insurance coverageUnderwritten by Blue Shield of California Life & Health Insurance Company.

Monthly rates

Amount of insuranceAge range $10,000 $30,000 $60,000 $90,000 $100,000

1 to 18* $1.95 $2.95 N/A N/A N/A

19 to 29 $2.75 $5.35 $9.25 $13.15 $14.45

30 to 39 $3.05 $6.25 $11.05 $15.85 $17.45

40 to 49 $5.85 $14.65 $27.85 $41.05 $45.45

50 to 59 $13.85 $38.65 $75.85 $113.05† $125.45†

60 to 64 $20.45 $58.45 $115.45 $172.45† $191.45†

Plan rates are effective October 1, 2010, and subject to change.

Please note: Individual term life insurance is available to primary subscribers (ages 1 to 64) of any Blue Shield health plan except for HIPAA guaranteed-issue and Kids Guaranteed-Issue plans. All plans terminate at age 65.

Dental and dental + vision coverage

Monthly rates

Specialty DuoSM

dental + vision package‡ Dental PPO Value SmileSM PPO‡ Dental HMO

Adult/child $51.70 $38.50 $23.50 $18.40

Adult and spouse/domestic partner

$107.20 $78.00 $46.30 $36.60

Adult and child $78.40 $58.30 $35.50 $32.40

Adult and children $116.50 $86.90 $53.10 $37.80

Family $181.70 $135.40 $82.60 $71.20

Plan rates are effective November 1, 2011, and subject to change.

Please note: Monthly rates for individual term life, Specialty Duo package, and dental plans are in addition to the monthly rates for medical benefits covered by the Blue Shield health plan. To be eligible for a dental plan or Specialty Duo package, you must be a California resident at the time of enrollment. If you had a Blue Shield individual and family dental plan or dental + vision package cancelled, you must wait six months from the date of cancellation before you can reapply.

If you choose a dental plan with your medical plan:

In most cases, you will receive one bill that combines your health, dental and, if applicable, life insurance dues/premiums.

If you choose a dental plan independent of a Blue Shield medical plan:

You will receive a separate bill for your dental coverage.

If you select an HMO medical plan, your Dental HMO plan and health coverage effective dates must be the first of the month. No benefits are paid for services received before the effective date. If you select a PPO medical plan along with a dental plan, you may request any effective date for both plans.

* Those under age 19 are not eligible for $60,000, $90,000, and $100,000 benefit amounts. To be eligible for individual term life, applicants must be approved in Tiers 1 through 4 by underwriting.

† $90,000 and $100,000 benefit amounts are not available for new sales to those 50 years of age or older. These members can purchase $10,000, $30,000 and $60,000 in coverage. Existing members who purchased $90,000 or $100,000 individual term life insurance prior to age 50, and who subsequently reach age 50, are eligible to keep their original coverage until age 65.

‡ Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Pending regulatory approval.


Dental plans and dental + vision package available with or independent of Blue Shield medical plans

Specialty DuoSM dental + vision package1 Highlights MatrixThis chart is only a summary. For a complete list of the benefits, exclusions, and limitations of the Specialty Duo dental plan and Specialty Duo vision plan, please refer to the Specialty Duo Dental Plan and Specialty Duo Vision Plan policy. To request a copy before you apply, call us at (800) 431-2809.

Specialty Duo Dental Benefits1,2,3

Calendar Year Deductible $50 per person

Calendar Year Benefit Maximum

$1,000 ($500 maximum may be used for non-network dentists)4

ServiceWith network dentists, you pay:

With non-network dentists the plan reimburses you up to:

Diagnostic services

Comprehensive oral exams $0 $40

Preventive care

Prophylaxis (cleanings, one every 6 months) Adult $0 $48

Child $0 $34

Sealant/per tooth5 (covered to age 16)

$0 $22

Restorative services3

One-surface composite (filling)

$37 $30

Crown (porcelain fused to noble metal)

$320 $256

Endodontics3

Anterior root canal $156 $125

Molar root canal $234 $187

Periodontics3

Osseous surgery/ per quadrant

$263 $210

Periodontal root planing/per quadrant

$65 $52

Prosthetics3

Bridge Pontic/False Tooth – High Noble Metal (per unit)

$293 $234

BridgeRetainer–PorcelainFused to High Noble Metal (per unit)

$313 $250

Complete denture (upper or lower)

$388 $310

Oral surgery3

Extraction (single tooth) $40 $32

Removalofimpactedtooth(complete bony)

$113 $90

Services for pregnant women6 (not subject to plan deductibles with network dentists)

$0 100% of charge

Orthodontics3,6,7

Fully banded (two-year) case – child

$2,3509 Not covered

Fully banded (two-year) case – adult

$2,6509 Not covered

Note: Dental diagnostic and preventive services are not subject to plan deductibles.

Specialty Duo vision plan benefits1

Service and eyewear

Plan coverage when provided by network providers

Plan coverage when provided by non-network providers

Comprehensive examination – every 12 months

Ophthalmologic 100% Up to a maximum of $60

Optometric 100% Up to a maximum of $50

Lenses12,13 – every 24 months (or 12 months with a prescription change)

Single vision 100% Up to a maximum of $43

Bifocal 100% Up to a maximum of $60

Trifocal 100% Up to a maximum of $75

Aphakic or lenticular monofocal

100% Up to a maximum of $120

Aphakic or lenticular multifocal

100% Up to a maximum of $200

Polycarbonate lenses for covered dependent children

Up to a maximum of $100


Frame – every 24 months Up to a maximum of $10014


Contact lenses13,15 – every 24 months (or 12 months with a prescription change)

Non-elective (medically necessary)16

Hard 100% Up to a maximum of $200

Soft 100% Up to a maximum of $250

Elective contact lenses (cosmetic/convenience)



Plano (non-prescription) sunglasses15,17


Not covered

Diabetes management referral18

100% Not covered


Dental PPO, Value Smile PPO, and Dental HMO Highlights MatrixThis chart is only a summary. For a complete list of the benefits, exclusions, and limitations, please refer to the EOC/Policy for the plan. To request a copy before you apply, call us at (800) 431-2809.

Dental PPO2,3 Value Smile PPO1,2 Dental HMO8,10

Calendar Year Deductible $50 per person $25 per person $0

Calendar Year Benefit Maximum

$1,000 ($500 maximum may be used for non-network dentists)4

$5004 $0

Service With network dentists, you pay:


With network dentists, you pay:


You pay:

Diagnostic services

Comprehensive oral exams $0 $40 $0 $40 $0

Preventive care

Prophylaxis (cleanings, one every 6 months)

Adult $0 $48 $0 $48 $0

Child $0 $34 $0 $34 $0

Sealant/per tooth5 (covered to age 16)

$0 $22 $0 $22 $11

Restorative services3

One-surface composite (filling)

$37 $30 $37 $30 $18

Crown (porcelain fused to noble metal)

$320 $256 Not covered Not covered $30011

Endodontics3

Anterior root canal $156 $125 Not covered Not covered $155

Molar root canal $234 $187 Not covered Not covered $290

Periodontics3

Osseous surgery/per quadrant


Periodontal root planing/per quadrant


Prosthetics3

Bridge Pontic/False Tooth - High Noble Metal (per unit)


BridgeRetainer-PorcelainFused to High Noble Metal (per unit)


Complete denture (upper or lower)


Oral surgery3

Extraction (single tooth) $40 $32 Not covered Not covered $34

Removalofimpactedtooth(complete bony)


Services for pregnant women6 (not subject to plan deductibles with network dentists)

$0 100% of charge $0 $48 Not covered

Orthodontics3,7

Fully banded (two year) case – child

$2,3509 Not covered Not covered Not covered $2,35010

Fully banded (two year) case – adult

$2,6509 Not covered Not covered Not covered $2,65010

Note: Diagnostic and preventive services are not subject to plan deductibles.


1 Underwritten by Blue Shield of California Life & Health Insurance Company (Blue Shield Life). Pending regulatory approval.

2 Use any network dentist to take advantage of contracted rates and pay lower out-of-pocket costs. When you use dentists who are not in our network, the plan reimburses up to the amount listed and you are responsible for all charges in excess of that amount and your calendar-year deductible.

3 Specialty Duo dental plan and Dental PPO plan members have certain waiting periods: three months for minor restorative services and procedures (such as fillings), endodontics, periodontics and oral surgery; 12 months for major restorative services and procedures (such as crowns), orthodontics, and removable and fixed prosthetics.

4 Each calendar year, the member is responsible for all charges incurred after the plan has paid these amounts for covered dental benefits.

5 Coverage for sealants is limited to the first and second permanent molars.

6 One additional routine adult prophylaxis (including periodontal prophylaxis for gingivitis) for women during pregnancy and one periodontal maintenance visit if warranted by a history of periodontal treatment and one course (up to four quadrants) of periodontal scaling and root planing for women during pregnancy with a documented existing periodontal condition. Value Smile PPO covers one additional routine adult prophylaxis only.

7 You pay the copayment plus up to $250 for records.

8 All services must be performed, prescribed or authorized by your dentist, chosen from the Blue Shield Dental HMO Dental Provider Directory. If you need to see a specialist, you must get a referral from your dental provider to receive covered services.

9 Orthodontic services have a fixed patient copayment and do not apply to your $1,000 network plan maximum.

10 Dental HMO members have a 12-month waiting period for orthodontics. (There are no waiting periods for other covered services.)

11 You pay the copayment plus the cost of precious or semi-precious metals.

12 Each pair of lenses includes a pink or rose tint No. 1 or No. 2 in the allowance and up to 61mm in size.

13 A prescription change means any of the following: a change in prescription of 0.50 diopter or more; a shift in axis of astigmatism of 15 degrees; a difference in vertical prism greater than 1 prism diopter; or a change in lens type.

14 When the participating provider uses wholesale or warehouse pricing, the maximum allowable frame allowance will be as follows: wholesale allowance − $66.04, warehouse allowance − $69.09. Note that this pricing replaces the frame allowance shown in the Summary of Benefits. Network providers using wholesale or warehouse pricing are identified in the Directory of Network Vision Providers. You pay any cost above the allowed amount.

15 In lieu of lenses and frame.

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

17 FormemberswhohavehadPRK,LASIK,orcustomLASIKvisioncorrectionsurgeryonly,thisbenefitofplanosunglassesallowanceisequaltotheplan’sframe allowance. An eye exam by a network provider is required to verify laser surgery or a note from the surgeon who performed the laser surgery is required to verify laser surgery. Available once every 24 months.

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


FAQs

Is my doctor part of a Blue Shield network?

Blue Shield’s HMO and PPO networks are among the largest in California, so chances are good your doctor is part of our network if you are already seeing one. It’s easy to see if your doctor participates in our network by going to Find a Provider on our website, blueshieldca.com. You can also locate network hospitals, dentists, optometrists, dermatologists, mental health providers, chiropractors, and acupuncturists.

Is my prescription on Blue Shield’s formulary?

To see if the prescriptions you take are on our formulary, go to blueshieldca.com and click on Pharmacy, then click Drug Database & Formulary to search for the drug name. Also check the specific plan information in this booklet to see the prescription coverage that comes with each plan.

How do deductibles work?

If your health plan has a deductible, you must pay this amount each year before Blue Shield makes payments toward covered services. Depending on your plan, some benefits and services such as generic prescription drug coverage and preventive care may be covered by Blue Shield before you meet your deductible.

Also, if your plan has an individual and family deductible and you have family coverage, a family deductible applies. Typically this means that the individual deductibles paid by covered family members count toward the family deductible, and once the family deductible is met, the individual deductibles are also met.

Is preventive care covered?

Yes. To help our members stay healthy, all Blue Shield health plans cover a range of preventive care such as routine physical exams, immunizations, well-baby care, and annual gynecological exams at no cost before any deductible must be met. Please look at each plan’s benefit summary for specific benefit coverage. You may also view the Blue Shield Preventive Guidelines at blueshieldca.com/preventive.

Can individual members of my family have different plans?

Yes. It may best suit your needs to cover your family members with different plans.

For specific benefit details, see the plan’s EOC/Policy.

A

n In

de

pe

nd

en

t M

em

be

r o

f th

e B

lue

Sh

ield

Ass

oc

iatio

n

A

166

46-R

EV(

3/12

)

50 Beale Street, San Francisco, CA 94105(415) 229-5000

Documents

choosing your health plan - California Health Insurance · choosing your health plan 1 We’re here for you When it comes to your health, we’re here to support you. We have the