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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.