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

Coverage Period: Beginning On or After 1/1/2024

Blue Shield Trio Bronze 60 HMO 7000/70 + Child Dental Alt Coverage for: Individual + Family | Plan Type: HMO
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/M0033837_EOC.pdf
or call 1-888-319-5999. 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:
Generally, you must pay all of the costs from providers up to the deductible amount before
What is the overall $7,000 per individual / $14,000 per this plan begins to pay. If you have other family members on the plan each family member
deductible? family for participating providers. must meet their own individual deductible until the total amount of deductible expenses paid
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?
The out-of-pocket limit is the most you could pay in a year for covered services. If you have
What is the out-of-pocket $9,100 per individual / $18,200 per
other family members in this plan, they have to meet their own out-of-pocket limits until the
limit for this plan? family for participating providers.
overall family out-of-pocket limit has been met.
Copayments for certain services,
What is not included in
premiums, and health care this plan Even though you pay these expenses, they don’t count toward the out-of-pocket limit.
the out-of-pocket limit?
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/fad 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
1-888-319-5999 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 This plan will pay some or all of the costs to see a specialist for covered services but only if
Yes.
see a specialist? you have a referral before you see the 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
Services You May Need Participating Provider
Event
(You will pay the least)
Primary care visit to treat an $70/visit; deductible does not
injury or illness apply
Trio+ Specialist: $80/visit;
deductible does not apply
If you visit a health Specialist visit
Other Specialist: $80/visit;
care provider's office
deductible does not apply
or clinic
Preventive care/screening No Charge; deductible does
/immunization not apply
Lab & Path: $65/visit;
deductible does not apply
X-Ray & Imaging: $115/visit;
Diagnostic test (x-ray, blood
deductible does not apply
work)
Other Diagnostic Examination:
If you have a test $115/visit; deductible does not
apply
Outpatient Radiology Center:
$400/visit; deductible does not
Imaging (CT/PET scans, MRIs)
apply
Outpatient Hospital: $400/visit
Retail:
If you need drugs to
Level A: $25/prescription
treat your illness or Tier 1
Level B: $30/prescription
condition
Mail Service: $50/prescription
More information about
Retail:
prescription drug
Level A: $115/prescription
coverage is available at
Tier 2 Level B: $145/prescription
blueshieldca.com/
Mail Service:
formulary
$230/prescription
* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033837_EOC.pdf.
Limitations, Exceptions, & Other
Non-Participating Provider
Important Information
(You will pay the most)
Not Covered ----------------------None-----------------------
Self-referral is available for Trio+
Not Covered
Specialist visits.
You may have to pay for services that
aren’t preventive. Ask your provider if
Not Covered
the services needed are preventive.
Then check what your plan will pay for.
Lab & Path: Not Covered
Preauthorization is required. Failure to
X-Ray & Imaging: Not
obtain preauthorization may result in
Covered
non-payment of benefits. The services
Other Diagnostic
listed are at a freestanding location.
Examination: Not Covered
Outpatient Radiology Center:
Preauthorization is required. Failure to
Not Covered
obtain preauthorization may result in
Outpatient Hospital: Not
non-payment of benefits.
Covered
Preauthorization is required for select
Retail: Not Covered drugs. Failure to obtain
Mail Service: Not Covered preauthorization may result in non-
payment of benefits.
Retail: Covers up to a 30-day supply;
90-days may be covered with a
Retail: Not Covered
copayment for each 30-day supply;
Mail Service: Not Covered
Mail Service: Covers up to a 90-day
supply.
Blue Shield of California is an independent member of the Blue Shield Association.
2 of 8

Common Medical
Services You May Need
Event
Tier 3
Tier 4
Facility fee (e.g., ambulatory
If you have outpatient surgery center)
surgery
Physician/surgeon fees
Emergency room care
Emergency medical
If you need immediate
transportation
medical attention
Urgent care
If you have a hospital
Facility fee (e.g., hospital room) 50% coinsurance
stay
* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033837_EOC.pdf.
What You Will Pay
Participating Provider
(You will pay the least)
Retail:
Level A: $160/prescription
Level B: $210/prescription
Mail Service:
$320/prescription
Retail and Network Specialty
Pharmacies: 50% coinsurance
up to $500/prescription Retail: Not Covered
Mail Service: 50% Mail Service: Not Covered
coinsurance up to
$1,000/prescription
Ambulatory Surgery Center:
50% coinsurance
Outpatient Hospital: 50%
coinsurance
$150/visit; deductible does not
apply
Facility Fee: 50% coinsurance
Physician Fee: 50%
coinsurance
50% coinsurance
$70/visit; deductible does not
apply
Limitations, Exceptions, & Other
Non-Participating Provider
Important Information
(You will pay the most)
Retail: Not Covered
Mail Service: Not Covered
Preauthorization is required. Failure to
obtain preauthorization may result in
non-payment of benefits.
Retail and Network Specialty
Pharmacies: Covers up to a 30-day
supply; Specialty drugs must be
obtained at a Network Specialty
Pharmacy.
Mail Service: Covers up to a 90-day
supply.
Ambulatory Surgery Center:
Not Covered
Outpatient Hospital: Not
----------------------None-----------------------
Covered
Not Covered
Facility Fee: 50%
coinsurance
----------------------None-----------------------
Physician Fee: 50%
coinsurance
This payment is for emergency or
50% coinsurance
authorized transport.
Within Plan Service Area:
Not Covered
Outside Plan Service Area: ----------------------None-----------------------
$70/visit; deductible does not
apply
Preauthorization is required. Failure to
Not Covered obtain preauthorization may result in
non-payment of benefits.
Blue Shield of California is an independent member of the Blue Shield Association.
3 of 8
 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)
50% coinsurance; deductible
Physician/surgeon fees Not Covered ----------------------None-----------------------
does not apply
Office Visit: $70/visit;
deductible does not apply
Other Outpatient Services: Office Visit: Not Covered
$150/visit; deductible does not Other Outpatient Services:
Preauthorization is required except for
apply Not Covered
office visits and office-based opioid
Outpatient services Partial Hospitalization: Partial Hospitalization: Not
treatment. Failure to obtain
$150/visit; deductible does not Covered
preauthorization may result in non-
If you need mental apply Psychological Testing: Not
payment of benefits.
health, behavioral Psychological Testing: Covered
health, or substance $150/visit; deductible does not
abuse services apply
Physician Inpatient Services:
Physician Inpatient Services:
50% coinsurance; deductible
Not Covered
does not apply Preauthorization is required. Failure to
Hospital Services: Not
Inpatient services Hospital Services: 50% obtain preauthorization may result in
Covered
coinsurance non-payment of benefits.
Residential Care: Not
Residential Care: 50%
Covered
coinsurance
No Charge; deductible does
Office visits Not Covered
not apply
Childbirth/delivery professional 50% coinsurance; deductible
If you are pregnant Not Covered ----------------------None-----------------------
services does not apply
Childbirth/delivery facility
50% coinsurance Not Covered
services
Preauthorization is required. Failure to
obtain preauthorization may result in
50% coinsurance; deductible
Home health care Not Covered non-payment of benefits. Coverage
If you need help does not apply
limited to 100 visits per member per
recovering or have
Calendar Year.
other special health
Office Visit: $70/visit;
needs Office Visit: Not Covered
deductible does not apply
Rehabilitation services Outpatient Hospital: Not ----------------------None-----------------------
Outpatient Hospital: $70/visit;
Covered
deductible does not apply

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

* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033837_EOC.pdf. 4 of 8
 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)
Office Visit: $70/visit;
Office Visit: Not Covered
deductible does not apply
Habilitation services Outpatient Hospital: Not
Outpatient Hospital: $70/visit;
Covered
deductible does not apply
Preauthorization is required. Failure to
Freestanding SNF: 50% Freestanding SNF: Not
obtain preauthorization may result in
coinsurance Covered
Skilled nursing care non-payment of benefits. Coverage
Hospital-based SNF: 50% Hospital-based SNF: Not
limited to 100 days per member per
coinsurance Covered
benefit period.
Preauthorization is required. Failure to
50% coinsurance; deductible
Durable medical equipment Not Covered obtain preauthorization may result in
does not apply
non-payment of benefits.
Preauthorization is required except for
No Charge; deductible does pre-hospice consultation. Failure to
Hospice services Not Covered
not apply obtain preauthorization may result in
non-payment of benefits.
No Charge; deductible does Coverage limited to one exam per
Children's eye exam Not Covered
not apply member per Calendar Year.
Coverage is limited to one eyeglass
frame and eyeglass lenses or contact
No Charge; deductible does
If your child needs Children's glasses Not Covered lenses instead of eyeglasses, up to the
not apply
dental or eye care benefit per Calendar Year. The cost
listed is for Single Vision.
Coverage for prophylaxis services
No Charge; deductible does
Children's dental check-up Not Covered (cleaning) is limited to once in a six
not apply
month period.
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.)

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

* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033837_EOC.pdf. 5 of 8
 • 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 1-888-319-5999 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

Minimum Essential Coverage generally includes plans, health insurance available through the Marketplace or other individual market policies, Medicare, Medicaid,
CHIP, TRICARE, and certain other coverage. If you are eligible for certain types of Minimum Essential Coverage, you may not be eligible for the premium tax credit.

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.

* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033837_EOC.pdf. 6 of 8
Language Access Services:

–––––––––––––––––––––To see examples of how this plan might cover costs for a sample medical situation, see the next section.––––––––––––––––––––––
PRA Disclosure Statement
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The
valid OMB control number for this information collection is 0938-1146. The time required to complete this information collection is estimated to average 0.08 hours per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

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

* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/M0033837_EOC.pdf. 7 of 8
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 $7,000 ◼ The plan’s overall deductible $7,000 ◼ The plan’s overall deductible $7,000
◼ Specialist copayment $80 ◼ Specialist copayment $80 ◼ Specialist copayment $80
◼ Hospital (facility) coinsurance 50% ◼ Hospital (facility) coinsurance 50% ◼ Hospital (facility) coinsurance 50%
◼ Other copayment $65 ◼ Other copayment $65 ◼ Other copayment $115

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

Total Example Cost $12,700 Total Example Cost $5,600 Total Example Cost $2,800

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 $6,300 Deductibles $0 Deductibles $1,700
Copayments $800 Copayments $2,400 Copayments $700
Coinsurance $2,000 Coinsurance $400 Coinsurance $100
What isn’t covered What isn’t covered What isn’t covered
Limits or exclusions $60 Limits or exclusions $20 Limits or exclusions $0
The total Peg would pay is $9,160 The total Joe would pay is $2,820 The total Mia would pay is $2,500

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
 NOTICES AVAILABLE ONLINE
Nondiscrimination and Language Assistance Services
Blue Shield complies with applicable state and federal civil rights laws. We also offer language assistance services at no additional cost.
View our nondiscrimination notice and language assistance notice: blueshieldca.com/notices.
You can also call for language assistance services: (866) 346-7198 (TTY: 711).

If you are unable to access the website above and would like to receive a copy of the nondiscrimination notice and language assistance notice, please call
Customer Care at (888) 256-3650 (TTY: 711).

Servicios de asistencia en idiomas y avisos de no discriminación

Blue Shield cumple con las leyes de derechos civiles federales y estatales aplicables. También, ofrecemos servicios de asistencia en idiomas sin costo
adicional.

Vea nuestro aviso de no discriminación y nuestro aviso de asistencia en idiomas en blueshieldca.com/notices. Para obtener servicios de asistencia en idiomas,
también puede llamar al (866) 346-7198 (TTY: 711).

Si no puede acceder al sitio web que aparece arriba y desea recibir una copia del aviso de no discriminación y del aviso de asistencia en idiomas, llame a
Atención al Cliente al (888) 256-3650 (TTY: 711).

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Blue Shield of California is an independent member of the Blue Shield Association A52287GEN-NG_0122