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Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services

Coverage Period: Beginning On or After 1/1/2018


Full PPO Combined Deductible 15-250 90/70 Coverage for: Individual + Family | Plan Type: PPO
The Summary of Benefits and Coverage (SBC) document will help you choose a health plan. The SBC shows you how you and the plan would
share the cost for covered health care services. NOTE: Information about the cost of this plan (called the premium) will be provided separately.
This is only a summary. For more information about your coverage, or to get a copy of the complete terms of coverage, visit bsca.com/policies/M0013283_EOC.pdf
or call 1-888-256-1915. For general definitions of common terms, such as allowed amount, balance billing, coinsurance, copayment, deductible, provider, or other
underlined terms see the Glossary. You can view the Glossary at healthcare.gov/sbc-glossary or call 1-866-444-3272 to request a copy.
Important Questions Answers Why This Matters:
$250 per individual / $500 per family for Generally, you must pay all of the costs from providers up to the deductible amount before
What is the overall participating providers; $250 per this plan begins to pay. If you have other family members on the plan each family member
deductible? individual / $500 per family for non- must meet their own individual deductible until the total amount of deductible expenses paid
participating providers. by all family members meets the overall family deductible.
This plan covers some items and services even if you haven’t yet met the deductible
Are there services Yes. Preventive care and services
amount. But a copayment or coinsurance may apply. For example, this plan covers certain
covered before you meet listed in your complete terms of
preventive services without cost-sharing and before you meet your deductible. See a list of
your deductible? coverage.
covered preventive services at healthcare.gov/coverage/preventive-care-benefits.
Are there other
deductibles for specific No. You don’t have to meet deductibles for specific services.
services?
$2,250 per individual / $4,500 per
What is the out-of-pocket family for participating providers; The out-of-pocket limit is the most you could pay in a year for covered services. If you have
limit for this plan? $10,250 per individual / $20,500 per other family members in this plan, the overall family out-of-pocket limit must be met.
family for non-participating providers.
Copayments for certain services,
What is not included in
premiums, balance-billing charges, and Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
the out-of-pocket limit?
health care this plan doesn’t cover.
This plan uses a provider network. You will pay less if you use a provider in the plan’s
Yes. See blueshieldca.com/fap or call network. You will pay the most if you use an out-of-network provider, and you might receive
Will you pay less if you
1-888-256-1915 for a list of network a bill from a provider for the difference between the provider’s charge and what your plan
use a network provider?
providers. pays (balance billing). Be aware, your network provider might use an out-of-network provider
for some services (such as lab work). Check with your provider before you get services.
Do you need a referral to
No. You can see the specialist you choose without a referral.
see a specialist?

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


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All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies.
What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Participating Provider Non-Participating Provider
Event Important Information
(You will pay the least) (You will pay the most)
$15/visit; Calendar year
Primary care visit to treat an
medical deductible does not 30% coinsurance
injury or illness
apply
----------------------None-----------------------
$15/visit; Calendar year
If you visit a health
Specialist visit medical deductible does not 30% coinsurance
care provider's office
apply
or clinic
You may have to pay for services that
No Charge; Calendar year
Preventive care/screening aren’t preventive. Ask your provider if
medical deductible does not Not Covered
/immunization the services needed are preventive.
apply
Then check what your plan will pay for.
Lab & Path:
30% coinsurance
Lab & Path:
X-Ray & Imaging:
$15/visit
30% coinsurance
Diagnostic test (x-ray, blood X-Ray & Imaging: The services listed are at a
Other Diagnostic
work) $15/visit freestanding location.
Examination:
Other Diagnostic Examination:
30% coinsurance up to $350
$40/visit
If you have a test per day plus 100% of
additional charges
Outpatient Radiology Center:
Outpatient Radiology Center: 30% coinsurance
Preauthorization is required. Failure to
10% coinsurance Outpatient Hospital:
Imaging (CT/PET scans, MRIs) obtain preauthorization may result in
Outpatient Hospital: 30% coinsurance up to $350
non-payment of benefits.
10% coinsurance per day plus 100% of
additional charges
If you need drugs to Retail: 25% + Preauthorization is required for select
Retail: $10/prescription
treat your illness or Tier 1 $10/prescription drugs. Failure to obtain
Mail Service: $20/prescription
condition Mail Service: Not Covered preauthorization may result in non-
More information about Retail: 25% + payment of benefits.
prescription drug Retail: $25/prescription Retail: Covers up to a 30-day supply;
Tier 2 $25/prescription
coverage is available at Mail Service: $50/prescription Mail Service: Covers up to a 90-day
Mail Service: Not Covered

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


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What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Participating Provider Non-Participating Provider
Event Important Information
(You will pay the least) (You will pay the most)
blueshieldca.com/ Retail: 25% + supply.
Retail: $40/prescription
formulary Tier 3 $40/prescription
Mail Service: $80/prescription
Mail Service: Not Covered
Preauthorization is required. Failure to
obtain preauthorization may result in
Retail and Network Specialty non-payment of benefits.
Pharmacies: 30% coinsurance Retail: 25% of purchase price Retail and Network Specialty
up to $200/prescription + 30% coinsurance up to Pharmacies:
Tier 4
Mail Service: 30% $200/prescription Covers up to a 30-day supply; Specialty
coinsurance up to Mail Service: Not Covered Drugs must be obtained at a Network
$400/prescription Specialty Pharmacy.
Mail Service: Covers up to a 90-day
supply.
Ambulatory Surgery Center:
30% coinsurance up to $350
Ambulatory Surgery Center: per day plus 100% of
Facility fee (e.g., ambulatory 10% coinsurance additional charges
If you have outpatient ----------------------None-----------------------
surgery center) Outpatient Hospital: Outpatient Hospital:
surgery 10% coinsurance 30% coinsurance up to $350
per day plus 100% of
additional charges
Physician/surgeon fees 10% coinsurance 30% coinsurance ----------------------None-----------------------
Facility Fee: Facility Fee:
$100/visit+ 10% coinsurance; $100/visit+ 10% coinsurance;
Calendar year medical Calendar year medical
Emergency room care ----------------------None-----------------------
deductible does not apply deductible does not apply
Physician Fee: Physician Fee:
If you need immediate 10% coinsurance 10% coinsurance
medical attention
Emergency medical
10% coinsurance 10% coinsurance ----------------------None-----------------------
transportation
$15/visit; Calendar year
Urgent care medical deductible does not 30% coinsurance ----------------------None-----------------------
apply

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


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What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Participating Provider Non-Participating Provider
Event Important Information
(You will pay the least) (You will pay the most)
30% coinsurance up to $600 Preauthorization is required. Failure to
If you have a hospital Facility fee (e.g., hospital room) 10% coinsurance per day plus 100% of obtain preauthorization may result in
stay additional charges non-payment of benefits.
Physician/surgeon fees 10% coinsurance 30% coinsurance ----------------------None-----------------------
Office Visit: Office Visit:
$15/visit; Calendar year 30% coinsurance
medical deductible does not Other Outpatient Services:
apply 30% coinsurance Preauthorization is required except for
Other Outpatient Services: Partial Hospitalization: office visits. Failure to obtain
Outpatient services
10% coinsurance 30% coinsurance up to $350 preauthorization may result in non-
Partial Hospitalization: per day plus 100% of payment of benefits.
10% coinsurance additional charges
If you need mental Psychological Testing: Psychological Testing:
health, behavioral 10% coinsurance 30% coinsurance
health, or substance Physician Inpatient Services:
abuse services 30% coinsurance
Physician Inpatient Services: Hospital Services:
10% coinsurance 30% coinsurance up to $600
Preauthorization is required. Failure to
Hospital Services: per day plus 100% of
Inpatient services obtain preauthorization may result in
10% coinsurance additional charges
non-payment of benefits.
Residential Care: Residential Care:
10% coinsurance 30% coinsurance up to $600
per day plus 100% of
additional charges
Office visits 10% coinsurance 30% coinsurance
Childbirth/delivery professional ----------------------None-----------------------
10% coinsurance 30% coinsurance
services
If you are pregnant
30% coinsurance up to $600
Childbirth/delivery facility
10% coinsurance per day plus 100% of ----------------------None-----------------------
services
additional charges

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


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What You Will Pay
Common Medical Limitations, Exceptions, & Other
Services You May Need Participating Provider Non-Participating Provider
Event Important Information
(You will pay the least) (You will pay the most)
Preauthorization is required. Failure to
obtain preauthorization may result in
Home health care 10% coinsurance Not Covered non-payment of benefits. Coverage
limited to 100 visits per member per
calendar year.
Office Visit:
Office Visit: 30% coinsurance
$15/visit Outpatient Hospital:
Rehabilitation services
Outpatient Hospital: 30% coinsurance up to $350
$15/visit per day plus 100% of
additional charges
----------------------None-----------------------
Office Visit:
Office Visit: 30% coinsurance
If you need help $15/visit Outpatient Hospital:
Habilitation services
recovering or have Outpatient Hospital: 30% coinsurance up to $350
other special health $15/visit per day plus 100% of
needs additional charges
Freestanding SNF:
Preauthorization is required. Failure to
Freestanding SNF: 10% coinsurance
obtain preauthorization may result in
10% coinsurance Hospital-based SNF:
Skilled nursing care non-payment of benefits. Coverage
Hospital-based SNF: 30% coinsurance up to $600
limited to 100 days per member per
10% coinsurance per day plus 100% of
benefit period.
additional charges
Preauthorization is required. Failure to
Durable medical equipment 10% coinsurance 30% coinsurance obtain preauthorization may result in
non-payment of benefits.
Preauthorization is required except for
No Charge; Calendar year
pre-hospice consultation. Failure to
Hospice services medical deductible does not Not Covered
obtain preauthorization may result in
apply
non-payment of benefits.
Children's eye exam Not Covered Not Covered ----------------------None-----------------------
If your child needs
Children's glasses Not Covered Not Covered ----------------------None-----------------------
dental or eye care
Children's dental check-up Not Covered Not Covered ----------------------None-----------------------

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


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Excluded Services & Other Covered Services:
Services Your Plan Generally Does NOT Cover (Check your policy or plan document for more information and a list of any other excluded services.)
 Cosmetic surgery  Infertility Treatment  Private-duty nursing  Routine foot care
 Dental care (Adult)  Long-term care  Routine eye care (Adult)  Weight loss programs
 Non-emergency care when
 Hearing Aids
traveling outside the U.S.

Other Covered Services (Limitations may apply to these services. This isn't a complete list. Please see your plan document.)
 Acupuncture  Bariatric surgery  Chiropractic Care

Your Rights to Continue Coverage: There are agencies that can help if you want to continue your coverage after it ends. The contact information for those
agencies is: Department of Health and Human Services, Center for Consumer Information and Insurance Oversight, at 1-877-267-2323 x61565 or cciio.cms.gov.
Other coverage options may be available to you too, including buying individual insurance coverage through the Health Insurance Marketplace. For more information
about the Marketplace, visit HealthCare.gov or call 1-800-318-2596.

Your Grievance and Appeals Rights:


There are agencies that can help if you have a complaint against your plan for a denial of a claim. This complaint is called a grievance or appeal. For more
information about your rights, look at the explanation of benefits you will receive for that medical claim. Your plan documents also provide complete information to
submit a claim, appeal, or a grievance for any reason to your plan. For more information about your rights, this notice or assistance, contact: Blue Shield Customer
Service at 1-888-256-1915 or the Department of Labor's Employee Benefits Security Administration at 1-866-444-EBSA (3272) or dol.gov/ebsa/healthreform.
Additionally, you can contact the California Department of Managed Health Care Help at 1-888-466-2219 or visit helpline@dmhc.ca.gov or visit
http://www.healthhelp.ca.gov.

Does this plan provide Minimum Essential Coverage? Yes


If you don’t have Minimum Essential Coverage for a month, you’ll have to make a payment when you file your tax return unless you qualify for an exemption from the
requirement that you have health coverage for that month.

Does this plan meet the Minimum Value Standards? Yes


If your plan doesn’t meet the Minimum Value Standards, you may be eligible for a premium tax credit to help you pay for a plan through the Marketplace.

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


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Language Access Services:

–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––

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


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About these Coverage Examples:

This is not a cost estimator. Treatments shown are just examples of how this plan might cover medical care. Your actual costs will be
different depending on the actual care you receive, the prices your providers charge, and many other factors. Focus on the cost sharing
amounts (deductibles, copayments and coinsurance) and excluded services under the plan. Use this information to compare the portion of
costs you might pay under different health plans. Please note these coverage examples are based on self-only coverage.

Peg is Having a Baby Managing Joe’s Type 2 Diabetes Mia’s Simple Fracture
(9 months of participating pre-natal care and a (a year of routine participating care of a well- (participating emergency room visit and follow up
hospital delivery) controlled condition) care)

 The plan’s overall deductible $250  The plan’s overall deductible $250  The plan’s overall deductible $250
 Specialist copayment $15  Specialist copayment $15  Specialist copayment $15
 Hospital (facility) coinsurance 10%  Hospital (facility) coinsurance 10%  Hospital (facility) coinsurance 10%
 Other copayment $15  Other copayment $15  Other copayment $15

This EXAMPLE event includes services like: This EXAMPLE event includes services like: This EXAMPLE event includes services like:
Specialist office visits (prenatal care) Primary care physician office visits (including Emergency room care (including medical
Childbirth/Delivery Professional Services disease education) supplies)
Childbirth/Delivery Facility Services Diagnostic tests (blood work) Diagnostic test (x-ray)
Diagnostic tests (ultrasounds and blood work) Prescription drugs Durable medical equipment (crutches)
Specialist visit (anesthesia) Durable medical equipment (glucose meter) Rehabilitation services (physical therapy)

Total Example Cost $12,800 Total Example Cost $7,400 Total Example Cost $2,500

In this example, Peg would pay: In this example, Joe would pay: In this example, Mia would pay:
Cost Sharing Cost Sharing Cost Sharing
Deductibles $250 Deductibles $120 Deductibles $250
Copayments $85 Copayments $785 Copayments $120
Coinsurance $1,224 Coinsurance $13 Coinsurance $135
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $1,783 Limits or exclusions $37
The total Peg would pay is $1,619 The total Joe would pay is $2,702 The total Mia would pay is $542

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


The plan would be responsible for the other costs of these EXAMPLE covered services. 8 of 8
Notice Informing Individuals about Nondiscrimination
and Accessibility Requirements

A49808-DMHC-REV (1/18)
Discrimination is against the law
Blue Shield of California complies with applicable state laws and federal civil rights laws, and does not discriminate on the basis of race,
color, national origin, ancestry, religion, sex, marital status, gender, gender identity, sexual orientation, age or disability. Blue Shield of
California does not exclude people or treat them differently because of race, color, national origin, ancestry, religion, sex, marital status,
gender, gender identity, sexual orientation, age, or disability.

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


Blue Shield of California: Phone: (844) 831-4133 (TTY: 711)
• P
 rovides aids and services at no cost to people with disabilities Fax: (844) 696-6070
to communicate effectively with us such as: Email: BlueShieldCivilRightsCoordinator@blueshieldca.com
- Qualified sign language interpreters You can file a grievance in person or by mail, fax or email. If
Written information in other formats (including large print,
-  you need help filing a grievance, our Civil Rights Coordinator is
audio, accessible electronic formats and other formats) available to help you.
• P
 rovides language services at no cost to people whose primary You can also file a civil rights complaint with the U.S. Department
language is not English such as: of Health and Human Services, Office for Civil Rights electronically
- Qualified interpreters through the Office for Civil Rights Complaint Portal, available at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf or by mail or phone at:
- Information written in other languages
If you need these services, contact the Blue Shield of California U.S. Department of Health and Human Services
Civil Rights Coordinator. 200 Independence Avenue SW.
Room 509F, HHH Building
If you believe that Blue Shield of California has failed to provide Washington, DC 20201
these services or discriminated in another way on the basis of (800) 368-1019; TTY: (800) 537-7697
race, color, national origin, ancestry, religion, sex, marital status,
Complaint forms are available at
gender, gender identity, sexual orientation, age, or disability, www.hhs.gov/ocr/office/file/index.html.
you can file a grievance with:
Blue Shield of California
Civil Rights Coordinator
P.O. Box 629007
El Dorado Hills, CA 95762-9007

Blue Shield of California
50 Beale Street, San Francisco, CA 94105 blueshieldca.com