Download Preferred Full HMO for Small Business $30

Preferred Full HMO for Small Business $30
Benefit Summary (For groups 1 to 50)
(Uniform Health Plan Benefits and Coverage Matrix)
Blue Shield of California
Effective January 1, 2014
THIS MATRIX IS INTENDED TO BE USED TO HELP YOU COMPARE COVERAGE BENEFITS AND IS A SUMMARY
ONLY. THE EVIDENCE OF COVERAGE AND PLAN CONTRACT SHOULD BE CONSULTED FOR A DETAILED
DESCRIPTION OF COVERAGE BENEFITS AND LIMITATIONS.
This health plan uses the Full HMO provider network
DEDUCTIBLE
Calendar Year Medical Deductible
Calendar Year Out-of-Pocket Maximum1
(For many covered services)
Calendar Year Brand Drug Deductible
LIFETIME BENEFIT MAXIMUM
Covered Services
$1,700 per individual /
$3,400 per family
$5,000 per individual /
$10,000 per family
$300 per individual /
$600 per family
None
Member Copayment
PROFESSIONAL SERVICES
Professional (Physician) Benefits
Physician and specialist office visits
$30 per visit
(Note: A woman may self-refer to an OB/GYN or family practice physician in her personal physician's medical
group or IPA for OB/GYN services)
Outpatient diagnostic X-ray and imaging
Outpatient diagnostic pathology and laboratory
Allergy Testing and Treatment Benefits
Office visits (includes visits for allergy serum injections)
SM
2
Access+ Specialist Benefits
Office visit, examination or other consultation (self-referred office visits and consultations only)
Preventive Health Benefits
Preventive health services (as required by applicable federal and California law)
OUTPATIENT SERVICES
Hospital Benefits (Facility Services)
Outpatient surgery performed at an ambulatory surgery center3
Outpatient surgery in a hospital
Outpatient services for treatment of illness or injury and necessary supplies
No Charge
No Charge
$30 per visit
$50 per visit
No Charge
$150 per surgery
$300 per surgery
No Charge
No Charge
20%
services and supplies, including subacute care)
Inpatient medically necessary skilled nursing services including subacute care4
EMERGENCY HEALTH COVERAGE
Emergency room services not resulting in admission (A copayment does not apply if the member
$150 per day
$200 per visit
is directly admitted to the hospital for inpatient services)
Emergency room physician services
AMBULANCE SERVICES
Emergency or authorized transport (ground or air)
PRESCRIPTION DRUG COVERAGE
A45917-REV (1/14)
5, 9, 10, 11
No Charge
$100
An Independent Member of the Blue Shield Association
(except as described under "Rehabilitation Benefits")
HOSPITALIZATION SERVICES
Hospital Benefits (Facility Services)
Inpatient physician services
Inpatient non-emergency facility services (semi-private room and board, and medically-necessary
Retail Prescriptions (up to a 30-day supply)
Contraceptive drugs and devices6
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
Mail Service Prescriptions (up to a 90-day supply)
Contraceptive drugs and devices6
Generic drugs
Preferred brand drugs
Non-preferred brand drugs
Specialty Pharmacies (up to a 30-day supply)
Specialty drugs (May require prior authorization from Blue Shield. Specialty drugs are covered only when
No Charge
$15 per prescription
$30 per prescription
$50 per prescription
No Charge
$30 per prescription
$60 per prescription
$100 per prescription
20% per prescription
dispensed by Network Specialty Pharmacies. Drugs from non-participating pharmacies are not covered except
in emergency and urgent situations.)
PROSTHETICS/ORTHOTICS
Prosthetic equipment and devices (separate office visit copayment may apply)
Orthotic equipment and devices (separate office visit copayment may apply)
No Charge
No Charge
DURABLE MEDICAL EQUIPMENT
Breast pump
Other durable medical equipment (member share is based upon allowed charges)
No Charge
50%
MENTAL HEALTH SERVICES (PSYCHIATRIC)16
Inpatient hospital services (prior authorization required)
Outpatient mental health services
20%
$30 per visit
(some services may require prior authorization and facility charges)
CHEMICAL DEPENDENCY SERVICES16
Inpatient hospital services for medical acute detoxification
20%
(prior authorization required)
Outpatient substance abuse services
$30 per visit
(some services may require prior authorization and facility charges)
HOME HEALTH SERVICES
Home health care agency services (up to 100 visits per calendar year)
Medical supplies (see "prescription drug coverage" for specialty drugs)
OTHER
Hospice Program Benefits
Routine home care
Inpatient respite care
24-hour continuous home care
Short-term inpatient care for pain and symptom management
Chiropractic Benefits
Chiropractic services (up to 15 visits per calendar year)
Acupuncture Benefits
Acupuncture visits
Pregnancy and Maternity Care Benefits
Prenatal and preconception physician office visits
$30 per visit
No Charge
No Charge
No Charge
No Charge
No Charge
$15 per visit1
$15 per visit
No Charge
(for inpatient hospital services, see "hospitalization services")
Postnatal Physician office visits
Family Planning and Infertility Benefits
Counseling and consulting7
Infertility services (member share is based upon allowed charges) (Diagnosis and treatment of cause of
$30 per visit
No Charge
50%1
infertility. Excludes in vitro fertilization, injectables for infertility, artificial insemination and GIFT)
Tubal ligation
Elective abortion8
Vasectomy8
Rehabilitation Benefits
No Charge
$100 per surgery
$75 per surgery
Office location (copayment applies to all places of services, including professional and facility settings)
Diabetes Care Benefits
Devices, equipment, and non-testing supplies (member share is based upon allowed charges; for
$30 per visit
50%
testing supplies see outpatient prescription drug benefits)
Diabetes self-management training
$30 per visit
Urgent Care Benefits (BlueCard® Program)
Urgent services outside your personal physician service area
$30 per visit
Optional Benefits
Optional dental and vision benefits are available. If your employer purchased any of these benefits, a description of the benefit is
provided separately.
Pediatric Vision Benefits (not subject to the calendar year medical deductible)
12
Comprehensive Eye Exam : one per calendar year
(includes dilation, if professionally indicated)
Ophthalmologic
- Routine ophthalmologic exam with refraction – new patient (S0620)
No Charge
- Routine ophthalmologic exam with refraction – established patient (S0621)
Optometric
- New patient exams (92002/92004)
No Charge
- Established patient exams (92012/92014)
Eyeglasses
Lenses: one pair per calendar year
- Single vision (V2100-2199)
- Conventional (Lined) bifocal (V2200-2299)
- Conventional (Lined) trifocal (V2300-2399)
No Charge
- Lenticular (V2121, V2221, V2321)
Lenses include choice of glass, plastic, or polycarbonate lenses, all lens powers (single vision, bifocal, trifocal,
lenticular), fashion and gradient tinting, scratch coating, oversized and glass-grey #3 prescription sunglass lenses.
Optional Lenses and Treatments
UV coating
Anti-reflective coating
High-index lenses
Photochromic lenses - plastic
Photochromic lenses – glass
Polarized lenses
Standard progressives
Premium progressives
Frame 13
No Charge
$35
$30
$25
$25
$45
$55
$95
(one frame per calendar year)
Collection frames
Non-Collection frames
Contact Lenses14
Non-Elective (Medically Necessary) – Hard or soft
One pair per Calendar Year
Elective (Cosmetic/Convenience) – Standard hard (V2500, V2510)
One pair per Calendar Year
Elective (Cosmetic/Convenience) – Non-standard hard (V2501-V2503, V2511-V2513, V2530-
No Charge
Up to $150 Maximum Allowance
No Charge
No Charge
No Charge
V2531)
One pair per Calendar Year
Elective (Cosmetic/Convenience) – Standard soft (V2520)
One pair per month, up to 6 months, per Calendar Year
Elective (Cosmetic/Convenience) – Non-standard soft (V2521-V2523)
One pair per month, up to 3 months, per Calendar Year
Other Pediatric Vision Benefits
Supplemental low-vision testing and equipment 15
No Charge
No Charge
35%
Diabetes management referral
No Charge
1.
Copayments marked with this footnote do not accrue to the calendar year out-of-pocket maximum. Copayments and charges for services not accruing to the member's
calendar year out-of-pocket maximum continue to be the member's responsibility after the calendar year out-of-pocket maximum is reached. Please refer to the
Summary of Benefits and Evidence of Coverage for exact terms and conditions of coverage.
2.
To use this option, members must select a Personal Physician who is affiliated with a medical group or IPA that is an Access+ provider group, which offers the Access+
Specialist feature. Members should then select a specialist within that medical group or IPA. Access+ Specialist visits for mental health or substance abuse services
must be provided by a MHSA network participating provider.
3.
Participating ambulatory surgery centers may not be available in all areas; however the member can obtain outpatient surgery services from a hospital or an ambulatory
surgery center affiliated with a hospital, with payment according to the hospital services benefit.
4.
Skilled nursing services are limited to 100 preauthorized days during a benefit period except when received through a hospice program provided by a participating
hospice agency. This 100 preauthorized day maximum on skilled nursing services is a combined maximum between SNF in a hospital unit and skilled nursing facilities
5.
Specialty Drugs are specific drugs used to treat complex or chronic conditions, which usually require close monitoring such as multiple sclerosis, hepatitis, rheumatoid
arthritis, cancers, and other conditions that are difficult to treat with traditional therapies. Specialty Drugs are listed in the Blue Shield Outpatient Drug Formulary.
Specialty Drugs may be self-administered in the home by injection by the member or family member (subcutaneously or intramuscularly), by inhalation, orally or
topically. Specialty Drugs may also require special handling, special manufacturing processes, and may have limited prescribing or limited pharmacy availability.
Specialty Drugs must be considered safe for self-administration by Blue Shield's Pharmacy & Therapeutics Committee, be obtained from a Blue Shield Specialty
Pharmacy, and may require prior authorization by Blue Shield. Infused or Intravenous (IV) medications are not considered Specialty Drugs.
6.
Contraceptive drugs and devices covered under the outpatient prescription drug benefits do not require a copayment. However, if a brand contraceptive is requested
when a generic equivalent is available, the member is responsible for paying the difference between the cost to Blue Shield for the brand contraceptive and its generic
drug equivalent. The difference in cost that the member must pay is not applied to the calendar year medical or brand drug deductible and is not included in the
calendar year out-of-pocket maximum responsibility calculation. In addition, select contraceptives may need prior authorization to be covered without a copayment.
7.
Includes insertion of IUD as well as injectable contraceptives for women.
8.
Copayment shown is for physician's services. If the procedure is performed in a facility setting (hospital or outpatient surgery center), an additional facility copayment
may apply.
9.
If the member or physician requests a brand drug when a generic drug equivalent is available, the member is responsible for the difference in cost between the brand
drug and its generic drug equivalent, in addition to the generic drug copayment. The difference in cost that the member must pay is not applied to the calendar year
medical or brand drug deductible and is not included in the calendar year out-of-pocket maximum responsibility calculation.
10.
This plan's prescription drug coverage is on average equivalent to or better than the standard benefit set by the federal government for Medicare Part D (also called
creditable coverage). Because this plan's prescription drug coverage is creditable, you do not have to enroll in a Medicare prescription drug plan while you maintain this
coverage. However, you should be aware that if you have a subsequent break in this coverage of 63 days or more anytime after you were first eligible to enroll in a
Medicare prescription drug plan, you could be subject to a late enrollment penalty in addition to your Part D premium.
11.
Drugs obtained at a non-participating pharmacy are not covered, unless Medically Necessary for a covered emergency, including drugs for emergency contraception.
12.
The comprehensive examination benefit allowance does not include fitting and evaluation fees for contact lenses.
13,
This Benefit covers Collection frames at no cost at participating independent and retail chain providers. Participating retail chain providers typically do not display the
frames as “Collection” but are required to maintain a comparable selection of frames that are covered in full. For non-Collection frames the allowable amount is up to
$150; however, if (a) the Participating Provider uses wholesale pricing, then the wholesale allowable amount will be up to $99.06, or if (b) the Participating Provider uses
warehouse pricing, then the warehouse allowable amount will be up to $103.64. Participating Providers using wholesale pricing are identified in the provider directory.
14.
Contact lenses are covered in lieu of eyeglasses once per Calendar Year. See the Definitions section in the Evidence of Coverage for the definitions of Elective Contact
Lenses and Non-Elective (Medically Necessary) Contact Lenses. A report from the provider and prior authorization from the Vision Plan Administrator (VPA) is required.
15.
A report from the provider and prior authorization from the contracted Vision Plan Administrator is required
16.
Mental health services are accessed through Blue Shield's Mental Health Service Administrator (MHSA) using Blue Shield's MHSA participating providers. For a listing
of severe mental illnesses, including serious emotional disturbances of a child, and other benefit details, please refer to the Summary of Benefits and Evidence of
Coverage. Inpatient services for acute detoxification are covered under the medical benefit; see the Hospital Benefits (Facility Services) section of the Evidence of
Coverage for benefit details. Services for medical acute detoxification are accessed through Blue Shield using Blue Shield participating providers.
Plan designs may be modified to ensure compliance with state and federal requirements.