HomeMy WebLinkAboutBlue Shield EPO Plan Summary
ASO_EPO (1/26) Plan ID: 45982 1
Summary of Benefits PRISM/Small Group Program Effective January 1, 2026 EPO Plan ASO EPO Plan
This Summary of Benefits shows the amount you will pay for Covered Services under this Claims Administrator benefit
plan. It is only a summary and it is included as part of the Benefit Booklet.1 Please read both documents carefully for
details.
Provider Network: Full PPO Network
This Plan uses a specific network of Health Care Providers, called the Full PPO provider network. Providers in this
network are called Participating Providers. This is an Exclusive Provider Organization (EPO) plan. You must receive all
Covered Services from a Participating Provider, but there are some exceptions. Please review your Benefit Booklet for
details about how to access care under this Plan. You can find Participating Providers in this network at
blueshieldca.com.
Calendar Year Deductibles (CYD)2
A Calendar Year Deductible (CYD) is the amount a Member pays each Calendar Year before the Claims Administrator
pays for Covered Services under the Plan. The Claims Administrator pays for some Covered Services before the
Calendar Year Deductible is met, as noted in the Benefits chart below.
When using a Participating Provider3
Calendar Year medical Deductible Individual coverage $300
Family coverage $300: individual
$600: Family
Calendar Year Out-of-Pocket Maximum4
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.
No Annual or Lifetime Dollar Limit
When using a Participating Provider3 Under this Plan there is no annual or
lifetime dollar limit on the amount
Claims Administrator will pay for
Covered Services.
Individual coverage $1,300
Family coverage $1,300: individual
$2,600: Family
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2
Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
Preventive Health Services6
Preventive Health Services $0
California Prenatal Screening Program $0
Physician services
Primary care office visit $30/visit
Specialist care office visit $30/visit
Physician home visit $0
Physician or surgeon services in an Outpatient Facility $0
Physician or surgeon services in an inpatient facility $0
Other professional services
Other practitioner office visit $30/visit
Includes nurse practitioners, physician assistants, and therapists.
Acupuncture services $30/visit
Combined with chiropractic services, up to 26 visits per Member,
per Calendar Year.
Chiropractic services $30/visit
Combined with acupuncture services, up to 26 visits per Member,
per Calendar Year.
Family planning
• Counseling, consulting, and education $0
• Injectable contraceptive $0
• Diaphragm fitting $0
• Intrauterine device (IUD) $0
• Insertion and/or removal of intrauterine device (IUD) $0
• Implantable contraceptive $0
• Tubal ligation $0
• Vasectomy $0
Podiatric services $30/visit
Medical nutrition therapy, not related to diabetes $0
Pregnancy and maternity care
Physician office visits: prenatal and postnatal $0
Physician services for pregnancy termination $0
3
Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
Emergency Services
Emergency room services $100/visit
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 $0
Urgent care center services $30/visit
Ambulance services $50/transport
This payment is for emergency or authorized transport.
Outpatient Facility services
Ambulatory Surgery Center $0
Outpatient Department of a Hospital: surgery $30/surgery
Outpatient Department of a Hospital: treatment of illness or injury,
radiation therapy, chemotherapy, and necessary supplies $0
Inpatient facility services
Hospital services and stay $0
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 $0
• Physician inpatient services $0
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 $0
Outpatient Facility services $30/surgery
Physician services $0
4
Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
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.
For the payments for Covered Services that are considered
Preventive Health Services, see Preventive Health Services.
Laboratory and pathology services
Includes diagnostic Papanicolaou (Pap) test.
• Laboratory center $0
• Outpatient Department of a Hospital $25/visit
Basic imaging services
Includes plain film X-rays, ultrasounds, and diagnostic
mammography.
• Outpatient radiology center $0
• Outpatient Department of a Hospital $25/visit
Other outpatient non-invasive diagnostic testing
Testing to diagnose illness or injury such as vestibular function
tests, EKG, cardiac monitoring, non-invasive vascular studies,
sleep medicine testing, muscle and range of motion tests, EEG,
and EMG.
• Office location $0
• Outpatient Department of a Hospital $25/visit
Advanced imaging services
Includes diagnostic radiological and nuclear imaging such as CT
scans, MRIs, MRAs, and PET scans.
• Outpatient radiology center $0
• Outpatient Department of a Hospital $100/visit
Rehabilitative and Habilitative Services
Includes physical therapy, occupational therapy, and respiratory
therapy.
Office location $30/visit
Outpatient Department of a Hospital $30/visit
Speech Therapy services
Office location $30/visit
Outpatient Department of a Hospital $30/visit
Durable medical equipment (DME)
DME 20%
Breast pump $0
5
Benefits5 Your payment
When using a Participating
Provider3
CYD2
applies
Orthotic equipment and devices 20%
Prosthetic equipment and devices 20%
Home health care services $30/visit
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. Includes home visits by a nurse,
Home Health Aide, medical social worker, physical therapist, speech
therapist, or occupational therapist, and medical supplies.
Home infusion and home injectable therapy services
Home infusion agency services $0
Includes home infusion drugs, medical supplies, and visits by a
nurse.
Hemophilia home infusion services $0
Includes blood factor products.
Skilled Nursing Facility (SNF) services
Up to 100 days per Member, per benefit period, except when
provided as part of a Hospice program. All days count towards the
limit, including days during any applicable Deductible period and
days in different SNFs during the Calendar Year.
Freestanding SNF $0
Hospital-based SNF $0
Hospice program services
Pre-Hospice consultation $0
Routine home care $0
24-hour continuous home care $0
Short-term inpatient care for pain and symptom management $0
Inpatient respite care $0
Other services and supplies
Diabetes care services
• Devices, equipment, and supplies $0
• Self-management training $30/visit
• Medical nutrition therapy $30/visit
Dialysis services $0
PKU product formulas and special food products $0
Allergy serum billed separately from an office visit $0
6
Mental Health and Substance Use Disorder Benefits Your payment
When using a Participating
Provider3
CYD2
applies
Outpatient services
Office visit, including Physician office visit $30/visit
Intensive outpatient care $0
Behavioral Health Treatment in an office setting $0
Behavioral Health Treatment in home or other non-institutional
setting $0
Office-based opioid treatment $0
Partial Hospitalization Program $0
Psychological Testing $0
Inpatient services
Physician inpatient services $0
Hospital services $0
Residential Care $0
Prior Authorization
The following are some frequently-utilized Benefits that require prior authorization:
• Advanced imaging services • Hospice program services
• Outpatient mental health services, except
office visits and office-based opioid
treatment
• Inpatient facility services
Please review the Benefit Booklet for more about Benefits that require prior authorization.
Notes
1 Benefit Booklet:
The Benefit Booklet describes the Benefits, limitations, and exclusions that apply to coverage under this Plan. Please
review the Benefit Booklet for more details of coverage outlined in this Summary of Benefits. You can request a copy
of the Benefit Booklet at any time.
Capitalized terms are defined in the Benefit Booklet. Refer to the Benefit Booklet for an explanation of the terms used
in this Summary of Benefits.
2 Calendar Year Deductible (CYD):
Calendar Year Deductible explained. A Calendar Year Deductible is the amount you pay each Calendar Year before
the Claims Administrator pays for Covered Services under the Plan.
If this Plan has any Calendar Year Deductible(s), Covered Services subject to that Deductible are identified with a
check mark () in the Benefits chart above.
Covered Services not subject to the Calendar Year medical Deductible. Some Covered Services received from
Participating Providers are paid by the Claims Administrator before you meet any Calendar Year medical Deductible.
7
Notes
These Covered Services do not have a check mark () next to them in the “CYD applies” column in the Benefits chart
above.
Family coverage has an individual Deductible within the Family Deductible. This means that the Deductible will be met
for an individual with Family coverage who meets the individual Deductible prior to the Family meeting the Family
Deductible within a Calendar Year.
3 Using Participating Providers:
Participating Providers have a contract to provide health care services to Members. When you receive Covered
Services from a Participating Provider, you are only responsible for the Copayment or Coinsurance, once any Calendar
Year Deductible has been met.
"Allowable Amount" is defined in the Benefit Booklet. In addition:
• Coinsurance is calculated from the Allowable Amount or Benefit maximum, whichever is less.
4 Calendar Year Out-of-Pocket Maximum (OOPM):
Calendar Year Out-of-Pocket Maximum explained. The Out-of-Pocket Maximum is the most you are required to pay
for Covered Services in a Calendar Year. Once you reach your Out-of-Pocket Maximum, the Claims Administrator will
pay 100% of the Allowable Amount for Covered Services for the rest of the Calendar Year.
Your payment after you reach the Calendar Year OOPM. You will continue to pay all charges for services that are not
covered, charges above the Allowable Amount, and charges for services above any Benefit maximum.
Any Deductibles count towards the OOPM. Any amounts you pay that count towards the Calendar Year medical
Deductible also count towards the Calendar Year Out-of-Pocket Maximum.
Family coverage has an individual OOPM within the Family OOPM. This means that the OOPM will be met for an
individual with Family coverage who meets the individual OOPM prior to the Family meeting the Family OOPM within
a Calendar Year.
5 Separate Member Payments When Multiple Covered Services are Received:
Each time you receive multiple Covered Services, you might have separate payments (Copayment or Coinsurance)
for each service. When this happens, you may be responsible for multiple Copayments or Coinsurance. For example,
you may owe an office visit payment in addition to an allergy serum payment when you visit the doctor for an allergy
shot.
6 Preventive Health Services:
If you only receive Preventive Health Services during a Physician office visit, there is no Copayment or Coinsurance for
the visit. If you receive both Preventive Health Services and other Covered Services during the Physician office visit,
you may have a Copayment or Coinsurance for the visit.
Plans may be modified to ensure compliance with Federal requirements.
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