Summary of benefits ppo benefit plan bronze 60 ppo

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

Summary of Benefits Bronze 60 PPO

Individual and Family Plan PPO Benefit Plan

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

Provider Network:

Exclusive PPO Network

This benefit plan uses a specific network of health care providers, called the Exclusive PPO provider network. Providers in this network are called participating providers. You pay less for covered services when you use a participating provider than when you use a non-participating provider. You can find participating providers in this network at .

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. Blue Shield pays for some covered services before the calendar year deductible is met, as noted in the Benefits chart below.

When using a participating

provider3

When using a nonparticipating provider4

Calendar year medical deductible Calendar year pharmacy deductible

Individual coverage Family coverage

Individual coverage Family coverage

$6,300

$6,300: individual $12,600: family

$500

$500: individual $1,000: family

$12,600 $12,600: individual $25,200: family not covered not covered

Calendar Year Out-of-Pocket Maximum5

An out-of-pocket maximum is the most a member will pay for covered services each calendar year. Any exceptions are listed in the Notes section at the end of this Summary of Benefits.

When using a participating

provider3

Individual coverage $7,000

Family coverage $7,000: individual $14,000: family

When using a nonparticipating provider4

$20,000

$20,000: individual $40,000: family

No Lifetime Benefit Maximum

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

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First Dollar Coverage:

3 office visits per calendar year

This benefit plan has first dollar coverage (FDC) for 3 office visits with participating providers. This means Blue Shield will pay for these covered services before you meet any calendar year medical deductible. These services are identified by a check mark () in the Benefits chart below.

First dollar coverage is available for office visits to a participating physician, participating health care provider, or mental health service administrator (MHSA) participating provider, for any combination of these services:

? Primary care office visit (by a primary care physician)

? Outpatient mental health and substance use disorder office visit

? Specialist care office visit

? Podiatric service

? Other practitioner office visit

? Teladoc consultation

? Acupuncture service

? Urgent care

After you reach the maximum number of visits under the first dollar coverage benefit, additional office visits in the same calendar year are subject to any calendar year medical deductible.

First dollar coverage is provided in addition to covered preventive health services office visits. Covered preventive health services are also paid by Blue Shield before you meet any calendar year medical deductible.

Benefits6

Preventive Health Services7

Physician services Primary care office visit 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 Teladoc consultation

When using a participating

provider3 $0

$75/visit $105/visit $105/visit

100% 100%

$75/visit

$75/visit Not covered

$5/consult

Your payment

CYD2 applies

FDC applies

When using a non-participating

provider4

CYD2 applies

Not covered

50%

50%

50%

50%

50%

50%

50%

Not covered

Not covered

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Benefits6

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 care7 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 Urgent care physician services 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

When using a participating

provider3 $0 $0 $0

100% Not covered

$105/visit

$0 100%

100%

$0 $75/visit

100%

100%

100%

100%

Your payment

CYD2 applies

FDC applies

When using a non-participating

provider4

CYD2 applies

Not covered

Not covered

Not covered

Not covered

Not covered

50%

50%

50%

100%

$0

50%

100%

50% up to

$300/day

plus 100% of

additional

charges

50% up to

$500/day

plus 100% of

additional

charges

50% up to

$500/day

plus 100% of

additional

charges

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Benefits6

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

Bariatric surgery services, designated California counties

This payment is for bariatric surgery services for residents of designated California counties. For bariatric surgery services for residents of non-designated California counties, the payments for Inpatient facility services/ Hospital services and stay and Physician inpatient and surgery services apply for inpatient services; or, if provided on an outpatient basis, the Outpatient facility services and Outpatient physician services payments apply.

Inpatient facility services Outpatient facility services Physician services

When using a participating

provider3 100%

100% 100%

100% 100% 100%

Your payment

CYD2 applies

FDC applies

When using a non-participating

provider4

CYD2 applies

50% up to

$500/day

plus 100% of

additional

charges

Not covered

Not covered

Not covered

Not covered

Not covered

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Benefits6

Diagnostic x-ray, imaging, pathology, and laboratory services

This payment is for covered services that are diagnostic, non-preventive health services, and diagnostic radiological procedures, such as CT scans, MRIs, MRAs, and PET scans. For the payments for covered services that are considered Preventive Health Services, see Preventive Health Services.

Laboratory services Includes diagnostic Papanicolaou (Pap) test. ? Laboratory center

? 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

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

When using a participating

provider3

$40/visit $40/visit

$0 100% 100%

100% 100%

Your payment

CYD2 applies

FDC applies

When using a non-participating

provider4

CYD2 applies

50%

50% up to

$500/day

plus 100% of

additional

charges

$0

50%

50% up to

$500/day

plus 100% of

additional

charges

50%

50% up to

$500/day

plus 100% of

additional

charges

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Benefits6

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

When using a participating

provider3

100%

100%

$75/visit $75/visit

100% $0

100% 100%

100%

100% 100%

Your payment

CYD2 applies

FDC applies

When using a non-participating

provider4

CYD2 applies

50% up to

$300/day

plus 100% of

additional

charges

50% up to

$500/day

plus 100% of

additional

charges

50%

50% up to

$500/day

plus 100% of

additional

charges

50%

Not covered

50%

50%

Not covered

Not covered

Not covered

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