Summary of benefits group plan blue shield of california

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Summary of Benefits Platinum Access+ HMO? 0/25 OffEx

Group Plan HMO Benefit Plan

This Summary of Benefits shows the amount you will pay for covered services under this Blue Shield of California benefit plan. It is only a summary and it is part of the contract for health care coverage, called the Evidence of Coverage (EOC).1 Please read both documents carefully for details.

Provider Network:

Access+ HMO Network

This benefit plan uses a specific network of health care providers, called the Access+ HMO provider network. Medical groups, independent practice associations (IPAs), and physicians in this network are called participating providers. You must select a primary care physician from this network to provide your primary care and help you access services, but there are some exceptions. Please review your Evidence of Coverage for details about how to access care under this plan. You can find participating providers in this network at .

Calendar Year Deductibles (CYD)2

A calendar year deductible (CYD) is the amount a member pays each calendar year before Blue Shield pays for covered services under the benefit plan.

When using a participating provider3

Calendar year medical and pharmacy deductible

Individual coverage $0

Family coverage $0: individual $0: family

Calendar Year Out-of-Pocket Maximum4

An out-of-pocket maximum is the most a member will pay for covered services each calendar year. Any exceptions are listed in the EOC.

No Lifetime Benefit Maximum

When using a participating provider3

Individual coverage $1,700 Family coverage $1,700: individual $3,400: family

Under this benefit plan there is no dollar limit on the total amount Blue Shield will pay for covered services in a member's lifetime.

Blue Shield of California is an independent member of the Blue Shield Association

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Benefits5

Preventive Health Services6

Physician services Primary care office visit Access+ specialist care office visit Other specialist care office visit Physician home visit Physician or surgeon services in an outpatient facility Physician or surgeon services in an inpatient facility

Other professional services Other practitioner office visit Includes nurses, nurse practitioners, and therapists. Acupuncture services Chiropractic services Up to 15 visits per member, per calendar year. Teladoc consultation Family planning ? Counseling, consulting, and education ? Injectable contraceptive; diaphragm fitting, intrauterine device (IUD), implantable contraceptive, and related procedure. ? Tubal ligation ? Vasectomy ? Infertility services Podiatric services

Pregnancy and maternity care6 Physician office visits: prenatal and initial postnatal Physician services for pregnancy termination

Emergency services and urgent care Emergency room services If admitted to the hospital, this payment for emergency room services does not apply. Instead, you pay the participating provider payment under Inpatient facility services/ Hospital services and stay. Emergency room physician services

Your payment When using a participating provider3

$0

CYD2 applies

$25/visit $50/visit $50/visit $50/visit

$0 $0

$25/visit

$15/visit $15/visit

$5/consult

$0

$0

$0 $75/surgery

50% $50/visit

$0 $100/surgery

$250/visit

$0

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Benefits5

Urgent care physician services Inside your primary care physician's service area, services must be provided or referred by your primary care physician or medical group/IPA. Services outside your primary care physician's service area are also covered. Services inside your primary care physician's service area not provided or referred by your primary care physician or medical group/IPA are not covered.

Ambulance services

Outpatient facility services Ambulatory surgery center Outpatient department of a hospital: surgery Outpatient department of a hospital: treatment of illness or injury, radiation therapy, chemotherapy, and necessary supplies

Inpatient facility services

Hospital services and stay

Transplant services This payment is for all covered transplants except tissue and kidney. For tissue and kidney transplant services, the payment for Inpatient facility services/ Hospital services and stay applies.

? Special transplant facility inpatient services

? Physician inpatient services

Diagnostic x-ray, imaging, pathology, and laboratory services This payment is for covered services that are diagnostic, nonpreventive health services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services that are considered Preventive Health Services, see Preventive Health Services. Laboratory services Includes diagnostic Papanicolaou (Pap) test. ? Laboratory center ? Outpatient department of a hospital ? California Prenatal Screening Program X-ray and imaging services Includes diagnostic mammography. ? Outpatient radiology center ? Outpatient department of a hospital

Your payment

When using a participating provider3

$25/visit

CYD2 applies

$100/transport

$100/surgery $150/surgery

$0

$250/day up to 3 days/admission

$250/day up to 3 days/admission

$0

$20/visit $20/visit

$0

$50/visit $50/visit

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Benefits5

Other outpatient diagnostic testing Testing to diagnose illness or injury such as vestibular function tests, EKG, ECG, cardiac monitoring, non-invasive vascular studies, sleep medicine testing, muscle and range of motion tests, EEG, and EMG. ? Office location ? Outpatient department of a hospital

Radiological and nuclear imaging services ? Outpatient radiology center ? Outpatient department of a hospital

Rehabilitation and habilitative services Includes physical therapy, occupational therapy, respiratory therapy, and speech therapy services. There is no visit limit for rehabilitation or habilitative services. Office location Outpatient department of a hospital

Durable medical equipment (DME) DME Breast pump Orthotic equipment and devices Prosthetic equipment and devices

Home health services Up to 100 visits per member, per calendar year, by a home health care agency. All visits count towards the limit, including visits during any applicable deductible period, except hemophilia and home infusion nursing visits.

Home health agency services Includes home visits by a nurse, home health aide, medical social worker, physical therapist, speech therapist, or occupational therapist.

Home visits by an infusion nurse Home health medical supplies Home infusion agency services

Your payment

When using a participating provider3

CYD2 applies

$50/visit $50/visit $50/visit $200/visit

$25/visit $25/visit

50% $0 $0 $0

$25/visit

$25/visit $0 $0

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Benefits5

Hemophilia home infusion services Includes blood factor products.

Skilled nursing facility (SNF) services Up to 100 days per member, per benefit period, except when provided as part of a hospice program. All days count towards the limit, including days during any applicable deductible period and days in different SNFs during the calendar year. Freestanding SNF Hospital-based SNF

Hospice program services Includes pre-hospice consultation, routine home care, 24-hour continuous home care, short-term inpatient care for pain and symptom management, and inpatient respite care.

Other services and supplies Diabetes care services ? Devices, equipment, and supplies ? Self-management training Dialysis services PKU product formulas and special food products Allergy serum

Mental Health and Substance Use Disorder Benefits

Mental health and substance use disorder benefits are provided through Blue Shield's mental health services administrator (MHSA).

Outpatient services Office visit, including physician office visit Other outpatient services, including intensive outpatient care, behavioral health treatment for pervasive developmental disorder or autism in an office setting, home, or other non-institutional facility setting, and office-based opioid treatment Partial hospitalization program Psychological testing

Inpatient services Physician inpatient services

Hospital services

Your payment

When using a participating provider3

$0

CYD2 applies

$100/day $100/day

$0

50% $0 $0 $0 50%

Your payment

When using a MHSA participating provider3

CYD2 applies

$25/visit

$0

$0 $0

$0 $250/day up to 3 days/admission

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