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HomeMy WebLinkAboutBlue Shield HMO 15 Summary of Benefits and CoverageBlue Shield of California is an independent member of the Blue Shield Association. 1 of 10 Summary of Benefits and Coverage: What this Plan Covers & What You Pay For Covered Services Coverage Period: 1/1/25 - 12/31/25 Custom Access+ HMO 15-0 Inpatient 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 myoptions.blueshieldca.com/prism or call 1-855-599-2650. 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. For your Pharmacy benefits through Express-Scripts (Medco) go to www.express-scripts.com or call 1-877-554-3091. Important Questions Answers Why This Matters: What is the overall deductible? $0. See the Common Medical Events chart below for your costs for services this plan covers. Are there services covered before you meet your deductible? Yes. Preventive care and services listed in your complete terms of coverage. This plan covers some items and services even if you haven’t yet met the deductible amount. But a copayment or coinsurance may apply. For example, this plan covers certain preventive services without cost-sharing and before you meet your deductible. See a list of covered preventive services at healthcare.gov/coverage/preventive-care-benefits. Are there other deductibles for specific services? No. You don’t have to meet deductibles for specific services. What is the out-of-pocket limit for this plan? $1,500 per individual / $3,000 per family for participating providers. Prescription: $5,100 per individual / $10,200 per family for participating providers. The out-of-pocket limit is the most you could pay in a year for covered services. If you have other family members in this plan, they have to meet their own out-of-pocket limits until the overall family out-of-pocket limit has been met. What is not included in the out-of-pocket limit? Copayments for certain services, prescription drug cost share out-of- network, any member prescription penalties (if applicable), premiums, and health care this plan doesn’t cover. Even though you pay these expenses, they don’t count toward the out-of-pocket limit. Will you pay less if you use a network provider? Yes. See blueshieldca.com/fad or call 1-855-599-2650 for a list of network providers. This plan uses a provider network. You will pay less if you use a provider in the plan’s network. You will pay the most if you use an out-of-network provider, and you might receive a bill from a provider for the difference between the provider’s charge and what your plan 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 see a specialist? Yes. This plan will pay some or all of the costs to see a specialist for covered services but only if you have a referral before you see the specialist. *For more information about limitations and exceptions, see the plan or policy document at myoptions.blueshieldca.com/prism. Blue Shield of California is an independent member of the Blue Shield Association. 2 of 10 All copayment and coinsurance costs shown in this chart are after your deductible has been met, if a deductible applies. Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) If you visit a health care provider's office or clinic Primary care visit to treat an injury or illness $15/visit Not Covered ----------------------None----------------------- Specialist visit Access+ Specialist: $30/visit Other Specialist: $15/visit Not Covered Self-referral is available for Access+ Specialist visits. Preventive care/screening /immunization No Charge Not Covered You may have to pay for services that aren’t preventive. Ask your provider if the services needed are preventive. Then check what your plan will pay for. If you have a test Diagnostic test (x-ray, blood work) Lab & Path: No Charge X-Ray & Imaging: No Charge Other Diagnostic Examination: No Charge Lab & Path: Not Covered X-Ray & Imaging: Not Covered Other Diagnostic Examination: Not Covered Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. The services listed are at a freestanding location. Imaging (CT/PET scans, MRIs) Outpatient Radiology Center: No Charge Outpatient Hospital: No Charge Outpatient Radiology Center: Not Covered Outpatient Hospital: Not Covered Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Pharmacy OOPM Out of Pocket Maximum (OOPM) $5,100 per individual / $10,200 per family Non-Participating Provider claims do not apply to the OOPM Member penalties including generic equivalent and retail refill allowance do not apply to the OOPM. Tier 1 - Typically Generic $5 Co-pay (retail) $10 Co-pay (mail order) $5 Co-pay (retail) Not Covered for mail order scripts Covers up to a 30-day supply (retail prescription); up to a 90-day supply (mail order prescription). For brand drugs that have a generic equivalent available: Member may pay the generic co-pay plus the difference in cost between the brand and generic drugs. *For more information about limitations and exceptions, see the plan or policy document at myoptions.blueshieldca.com/prism. Blue Shield of California is an independent member of the Blue Shield Association. 3 of 10 If you need drugs to treat your illness or condition More information about prescription drug coverage is available at www.express- scripts.com Tier 2 - Typically Preferred / Brand $10 Co-pay (retail) $20 Co-pay (mail order) $10 Co-pay (retail) Not Covered for mail order scripts For prepackaged drugs that have more than a 30 day supply, members will be charged up to 3 co-pays at a retail pharmacy per fill. Prior Authorization / Coverage Management programs may apply to some drugs 90 day supply for maintenance medication available through Express Scripts, Walgreens and CVS. Members who continue to fill 30-day supply after their 3rd fill will pay more of the prescription cost for their maintenance medication. Out of Pocket Maximum (OOPM) Member penalties including generic equivalent and retail refill allowance do not apply to the OOPM. Tier 3 - Typically Non-Preferred / Specialty Drugs $25 Co-pay (retail) $50 Co-pay (mail order) $25 Co-pay (retail) Not Covered for mail order scripts Specialty Drugs 20% to $100 max Not Covered If you have outpatient surgery Facility fee (e.g., ambulatory surgery center) Ambulatory Surgery Center: No Charge Outpatient Hospital: $100/surgery Ambulatory Surgery Center: Not Covered Outpatient Hospital: Not Covered ----------------------None----------------------- Physician/surgeon fees No Charge Not Covered If you need immediate medical attention Emergency room care Facility Fee: $50/visit Physician Fee: No Charge Facility Fee: $50/visit Physician Fee: No Charge ----------------------None----------------------- *For more information about limitations and exceptions, see the plan or policy document at myoptions.blueshieldca.com/prism. Blue Shield of California is an independent member of the Blue Shield Association. 4 of 10 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Emergency medical transportation $50/transport $50/transport This payment is for emergency or authorized transport. Urgent care $15/visit Within Plan Service Area: Not Covered Outside Plan Service Area: $15/visit ----------------------None----------------------- If you have a hospital stay Facility fee (e.g., hospital room) No Charge Not Covered Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Physician/surgeon fees No Charge Not Covered ----------------------None----------------------- If you need mental health, behavioral health, or substance abuse services Outpatient services Office Visit: $15/visit Other Outpatient Services: No Charge Partial Hospitalization: No Charge Psychological Testing: No Charge Office Visit: Not Covered Other Outpatient Services: Not Covered Partial Hospitalization: Not Covered Psychological Testing: Not Covered Preauthorization is required except for office visits and office-based opioid treatment. Failure to obtain preauthorization may result in non- payment of benefits. Inpatient services Physician Inpatient Services: No Charge Hospital Services: No Charge Residential Care: No Charge Physician Inpatient Services: Not Covered Hospital Services: Not Covered Residential Care: Not Covered Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. If you are pregnant Office visits No Charge Not Covered ----------------------None----------------------- Childbirth/delivery professional services No Charge Not Covered Childbirth/delivery facility services No Charge Not Covered If you need help recovering or have other special health needs Home health care $15/visit Not Covered Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Coverage limited to 100 visits per member per Calendar Year. *For more information about limitations and exceptions, see the plan or policy document at myoptions.blueshieldca.com/prism. Blue Shield of California is an independent member of the Blue Shield Association. 5 of 10 Common Medical Event Services You May Need What You Will Pay Limitations, Exceptions, & Other Important Information Participating Provider (You will pay the least) Non-Participating Provider (You will pay the most) Rehabilitation services Office Visit: $15/visit Outpatient Hospital: $15/visit Office Visit: Not Covered Outpatient Hospital: Not Covered ----------------------None----------------------- Habilitation services Office Visit: $15/visit Outpatient Hospital: $15/visit Office Visit: Not Covered Outpatient Hospital: Not Covered Skilled nursing care Freestanding SNF: No Charge Hospital-based SNF: No Charge Freestanding SNF: Not Covered Hospital-based SNF: Not Covered Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Coverage limited to 100 days per member per benefit period. Durable medical equipment 20% coinsurance Not Covered Preauthorization is required. Failure to obtain preauthorization may result in non-payment of benefits. Hospice services No Charge Not Covered Preauthorization is required except for pre-hospice consultation. Failure to obtain preauthorization may result in non-payment of benefits. If your child needs dental or eye care Children's eye exam Not Covered Not Covered ----------------------None----------------------- Children's glasses Not Covered Not Covered Children's dental check-up Not Covered Not Covered 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 •Hearing Aids •Non-emergency care when traveling outside the U.S. *For more information about limitations and exceptions, see the plan or policy document at myoptions.blueshieldca.com/prism. Blue Shield of California is an independent member of the Blue Shield Association. 6 of 10 Pharmacy Benefit Exclusions •Allergy Serums •Biologicals •Drugs used for cosmetic purposes •Drugs used to promote or stimulate hair growth •Blood or blood plasma products •Insulin Pumps •Non-Federal Legend Drugs •Drugs labeled “Caution-limited by Federal law to investigational use” or experimental drugs, even though a charge is made to the individual •Nutritional Supplements •Some or certain compounds are excluded •Ostomy Supplies •ACA Preventive Meds Contraceptives – Exception: covered for adults less than 51 years of age •ACA Preventive Meds Aspirin – Exception: covered for adults under 70 years of age •ACA Preventive Meds Folic Acid- Exception: covered for adults under 51 years of age •ACA Preventive Meds Fluoride -Exception: covered for children 6 months through 5 years of age •ACA Preventive Meds Smoking Cessation- Exception: covered for adults 18 years of age and over •ACA Preventive Meds - Breast Cancer Prevention, Exception: covered for adults 35 years of age and over •ACA Preventive Meds- Bowel Prep Agents Exception: covered for adults between the ages of 50 through 75 years •ACA Preventive Meds – Vitamin D Exception: Covered for adults age 65 years of age and over •Certain formulary exclusions apply, for more information on this as well as the latest drug coverage please visit our website www.express- scripts.com •ACA Preventive Meds - Statins Exception: Covered for adults 40-75 years of age 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 Other Pharmacy Benefit Inclusions •Specialty Drugs •Insulin •State Restricted Drugs •Needles and Syringes •Vaccines •Drugs to treat Impotency for males only age18 and over *For more information about limitations and exceptions, see the plan or policy document at myoptions.blueshieldca.com/prism. Blue Shield of California is an independent member of the Blue Shield Association. 7 of 10 •OTC Diabetic Supplies (except Insulin Pumps and Glucowatch products) •ACA Preventive Meds Aspirin –Exception: covered for adults under 70 years of age •ACA Preventive Meds Smoking Cessation-Exception: covered for adults 18 years ofage and over •ACA Preventive Meds Statins - Exception: covered for adults 40-75 years of age •ACA Preventive Meds Contraceptives – Exception: covered for adults less than 51years of age •ACA Preventive Meds Folic Acid-Exception: covered for adults under 51 years of age •ACA Preventive Meds - Breast Cancer Prevention, Exception: covered for adults 35 years of age and over •ACA Preventive Meds – Vitamin D Exception: Covered for adults age 65 years ofage and over •ACA Preventive Meds Fluoride -Exception: covered for children 6 months through 5 years of age •ACA Preventive Meds- Bowel Prep AgentsException: covered for adults between theages of 50 through 75 years •ACA Preventive Meds HIV – Exception: Covered for Generic Only 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 1-855-599-2650 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 Coverage Provide Minimum Essential Coverage? The Affordable Care Act requires most people to have health care coverage that qualifies as “minimum essential coverage.” This plan or policy does provide minimum essential coverage. Does this Coverage Meet the Minimum Value Standard? The Affordable Care Act establishes a minimum value standard of benefits of a health plan. The minimum value standard is 60% (actuarial value). This plan or policy does meet the minimum value standard for the benefits it provides. * For more information about limitations and exceptions, see the plan or policy document at myoptions.blueshieldca.com/prism. Blue Shield of California is an independent member of the Blue Shield Association. 8 of 10 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. The plan would be responsible for the other costs of these EXAMPLE covered services. 9 of 10 Peg is Having a Baby (9 months of participating pre-natal care and a hospital delivery) Managing Joe’s Type 2 Diabetes (a year of routine participating care of a well- controlled condition) Mia’s Simple Fracture (participating emergency room visit and follow up care) About these Coverage Examples: ◼The plan’s overall deductible $0 ◼Specialist copayment $15 ◼Hospital (facility) copayment $0 ◼Other copayment $0 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) Total Example Cost $12,700 In this example, Peg would pay: ◼The plan’s overall deductible $0 ◼Specialist copayment $15 ◼Hospital (facility) copayment $0 ◼Other copayment $0 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) Total Example Cost $5,600 In this example, Joe would pay: ◼The plan’s overall deductible $0 ◼Specialist copayment $15 ◼Hospital (facility) copayment $0 ◼Other copayment $0 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 $2,800 In this example, Mia would pay: Cost Sharing Deductibles $0 Copayments $0 Coinsurance $0 What isn’t covered Limits or exclusions $70 The total Peg would pay is $70 Cost Sharing Deductibles $0 Copayments $200 Coinsurance $200 What isn’t covered Limits or exclusions $3,500 The total Joe would pay is $3,900 Cost Sharing Deductibles $0 Copayments $200 Coinsurance $20 What isn’t covered Limits or exclusions $10 The total Mia would pay is $200 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. Blue Shield of California is an independent member of the Blue Shield Association. NOTICES AVAILABLE ONLINE 非歧視通知和語言協助服務 遵守適用的州及聯邦政府的民權法。同時，我們免費提供語言協助服務。 如需檢視我司的非歧視通知和語言幫助通知，請造訪 。您還可致電尋求語言協助服務： 。 如果您無法造訪上述網站，且希望收到一份非歧視通知和語言幫助通知的副本，請致電客戶服務部，電話： Blue Shield of California is an independent member of the Blue Shield Association A52287GEN-NG_0122 。