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

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

Platinum 90 Trio HMO 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/MG011318_EOC.pdf or call 1-844-250-2873. 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:
What is the overall
$0. See the Common Medical Events chart below for your costs for services this plan covers.
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 $4,500 per individual / $9,000 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
1-844-250-2873 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 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)
Primary care visit to treat an
$15/visit Not Covered ----------------------None-----------------------
injury or illness
Trio+ Specialist: $30/visit Self-referral is available for Trio+
If you visit a health Specialist visit Not Covered
Other Specialist: $30/visit Specialist visits.
care provider's office
You may have to pay for services that
or clinic
Preventive care/screening aren’t preventive. Ask your provider if
No Charge Not Covered
/immunization the services needed are preventive.
Then check what your plan will pay for.
Lab & Path: Not Covered
Lab & Path: $15/visit Preauthorization is required. Failure to
X-Ray & Imaging: Not
Diagnostic test (x-ray, blood X-Ray & Imaging: $30/visit obtain preauthorization may result in
Covered
work) Other Diagnostic Examination: non-payment of benefits. The services
Other Diagnostic
$30/visit listed are at a freestanding location.
If you have a test Examination: Not Covered
Outpatient Radiology Center:
Outpatient Radiology Center: Preauthorization is required. Failure to
Not Covered
Imaging (CT/PET scans, MRIs) $75/visit obtain preauthorization may result in
Outpatient Hospital: Not
Outpatient Hospital: $75/visit non-payment of benefits.
Covered
Retail: $7/prescription Retail: Not Covered Preauthorization is required for select
Tier 1
Mail Service: $21/prescription Mail Service: Not Covered drugs. Failure to obtain
Retail: $16/prescription Retail: Not Covered preauthorization may result in non-
Tier 2
Mail Service: $48/prescription Mail Service: Not Covered payment of benefits.
Retail: Covers up to a 30-day supply;
If you need drugs to Retail: $25/prescription Retail: Not Covered
Tier 3 Mail Service: Covers up to a 90-day
treat your illness or Mail Service: $75/prescription Mail Service: Not Covered supply.
condition
Preauthorization is required. Failure to
More information about
obtain preauthorization may result in
prescription drug
Retail and Network Specialty non-payment of benefits.
coverage is available at
Pharmacies: 10% coinsurance Retail and Network Specialty
blueshieldca.com/
up to $250/prescription Retail: Not Covered Pharmacies: Covers up to a 30-day
formulary Tier 4
Mail Service: 10% Mail Service: Not Covered supply; Specialty drugs must be
coinsurance up to obtained at a Network Specialty
$750/prescription Pharmacy.
Mail Service: Covers up to a 90-day
supply.

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/MG011318_EOC.pdf. 2 of 7
 What You Will Pay
Common Medical
Services You May Need Participating Provider
Event
(You will pay the least)
Ambulatory Surgery Center:
Facility fee (e.g., ambulatory $75/surgery
If you have outpatient
surgery center) Outpatient Hospital:
surgery
$75/surgery
Physician/surgeon fees $20/visit
Facility Fee: $150/visit
Emergency room care
Physician Fee: No Charge
Emergency medical
$150/transport
If you need immediate transportation
medical attention
Urgent care $15/visit
$225/day up to 5
If you have a hospital Facility fee (e.g., hospital room)
days/admission
stay
Physician/surgeon fees No Charge
Office Visit: $15/visit
Other Outpatient Services:
$15/visit
Outpatient services Partial Hospitalization:
$15/visit
If you need mental
Psychological Testing:
health, behavioral
$15/visit
health, or substance
Physician Inpatient Services:
abuse services
No Charge
Hospital Services: $225/day
Inpatient services
up to 5 days/admission
Residential Care: $225/day up
to 5 days/admission
Office visits No Charge
Childbirth/delivery professional
No Charge
If you are pregnant services
Childbirth/delivery facility $225/day up to 5
services days/admission
Limitations, Exceptions, & Other
Non-Participating Provider
Important Information
(You will pay the most)
Ambulatory Surgery Center:
Not Covered
Outpatient Hospital: Not ----------------------None-----------------------
Covered
Not Covered
Facility Fee: $150/visit
----------------------None-----------------------
Physician Fee: No Charge
This payment is for emergency or
$150/transport
authorized transport.
Within Plan Service Area:
Not Covered
----------------------None-----------------------
Outside Plan Service Area:
$15/visit
Preauthorization is required. Failure to
Not Covered obtain preauthorization may result in
non-payment of benefits.
Not Covered ----------------------None-----------------------
Office Visit: Not Covered
Other Outpatient Services:
Preauthorization is required except for
Not Covered
office visits and office-based opioid
Partial Hospitalization: Not
treatment. Failure to obtain
Covered
preauthorization may result in non-
Psychological Testing: Not
payment of benefits.
Covered
Physician Inpatient Services:
Not Covered
Preauthorization is required. Failure to
Hospital Services: Not
obtain preauthorization may result in
Covered
non-payment of benefits.
Residential Care: Not
Covered
Not Covered
Not Covered
----------------------None-----------------------
Not Covered

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/MG011318_EOC.pdf. 3 of 7

Common Medical
Services You May Need
Event
Home health care
Rehabilitation services
Habilitation services
If you need help
recovering or have
other special health
needs
Skilled nursing care
Durable medical equipment
Hospice services
Children's eye exam
If your child needs Children's glasses
dental or eye care
Children's dental check-up
* For more information about limitations and exceptions, see the plan or
policy document at bsca.com/policies/MG011318_EOC.pdf.
What You Will Pay
Participating Provider
(You will pay the least)
$20/visit
Office Visit: $15/visit
Outpatient Hospital: $15/visit
Office Visit: $15/visit
Outpatient Hospital: $15/visit
Freestanding SNF: $125/day
up to 5 days/admission
Hospital-based SNF:
$125/day up to 5
days/admission
10% coinsurance
No Charge
No Charge
No Charge
No Charge
Limitations, Exceptions, & Other
Non-Participating Provider
Important Information
(You will pay the most)
Preauthorization is required. Failure to
obtain preauthorization may result in
Not Covered non-payment of benefits. Coverage
limited to 100 visits per member per
Calendar Year.
Office Visit: Not Covered
Outpatient Hospital: Not
Covered
----------------------None-----------------------
Office Visit: Not Covered
Outpatient Hospital: Not
Covered
Preauthorization is required. Failure to
Freestanding SNF: Not
obtain preauthorization may result in
Covered
non-payment of benefits. Coverage
Hospital-based SNF: Not
limited to 100 days per member per
Covered
benefit period.
Preauthorization is required. Failure to
Not Covered obtain preauthorization may result in
non-payment of benefits.
Preauthorization is required except for
pre-hospice consultation. Failure to
Not Covered
obtain preauthorization may result in
non-payment of benefits.
Coverage limited to one exam per
Not Covered
member per Calendar Year.
Coverage is limited to one eyeglass
frame and eyeglass lenses or contact
Not Covered lenses instead of eyeglasses, up to the
benefit per Calendar Year. The cost
listed is for Single Vision.
Coverage for prophylaxis services
Not Covered (cleaning) is limited to once in a six
month period.
Blue Shield of California is an independent member of the Blue Shield Association.
4 of 7
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.)
• Non-emergency care when
• Chiropractic Care • Hearing Aids • Routine foot care
traveling outside the U.S.
• Cosmetic surgery • Infertility Treatment • Private-duty nursing • Weight loss programs
• Dental care (Adult) • Long-term care • Routine eye care (Adult)

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

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 1-844-250-2873. 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? Not Applicable
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/MG011318_EOC.pdf. 5 of 7
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/MG011318_EOC.pdf. 6 of 7
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 $0 ◼ The plan’s overall deductible $0 ◼ The plan’s overall deductible $0
◼ Specialist copayment $30 ◼ Specialist copayment $30 ◼ Specialist copayment $30
◼ Hospital (facility) copayment $225 ◼ Hospital (facility) copayment $225 ◼ Hospital (facility) copayment $225
◼ Other copayment $15 ◼ Other copayment $15 ◼ Other copayment $30

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 $0 Deductibles $0 Deductibles $0
Copayments $800 Copayments $600 Copayments $500
Coinsurance $0 Coinsurance $80 Coinsurance $30
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 $860 The total Joe would pay is $700 The total Mia would pay is $530

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. 7 of 7
 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