HomeMy WebLinkAboutBlue Shield Gold PPO Medicare Plan Summary
ASO_PPO (1/26) Plan ID: 46022 1
Summary of Benefits PRISM/Small Group Program Effective January 1, 2026 PPO Plan ASO PPO 80/50 Gold Retiree
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. You pay less for Covered Services when you use a Participating Provider
than when you use a Non-Participating Provider. 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 Participating3 or Non-
Participating4 Provider
Calendar Year medical Deductible Individual coverage $500
Family coverage $500: individual
$1,000: Family
Calendar Year Out-of-Pocket Maximum5
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 any combination of Participating3 or
Non-Participating4 Providers
Under this Plan there is no annual or
lifetime dollar limit on the amount
Claims Administrator will pay for
Covered Services. Individual coverage $1,500
Family coverage $1,500: individual
$3,000: Family
Bl
u
e
S
h
i
e
l
d
o
f
C
a
l
i
f
o
r
n
i
a
i
s
a
n
i
n
d
e
p
e
n
d
e
n
t
m
e
m
b
e
r
o
f
t
h
e
B
l
u
e
S
h
i
e
l
d
A
s
s
o
c
i
a
t
i
o
n
2
Benefits6 Your payment
When using a
Participating
Provider3
CYD2
applies
When using a
Non-Participating
Provider4
CYD2
applies
Preventive Health Services7
Preventive Health Services $0 Not covered
California Prenatal Screening Program $0 $0
Physician services
Primary care office visit $20/visit 50%
Specialist care office visit $20/visit 50%
Physician home visit 20% 50%
Physician or surgeon services in an Outpatient
Facility 20% 50%
Physician or surgeon services in an inpatient facility 20% 50%
Other professional services
Other practitioner office visit $20/visit 50%
Includes nurse practitioners, physician assistants,
and therapists.
Acupuncture services 20% 20%
Combined with chiropractic services, up to 26
visits per Member, per Calendar Year.
Chiropractic services
20%
Subject to a
Benefit maximum
of $50/visit
50%
Subject to a
Benefit maximum
of $25/visit
Combined with acupuncture services, up to 26
visits per Member, per Calendar Year.
Family planning
• Counseling, consulting, and education $0 Not covered
• Injectable contraceptive $0 Not covered
• Diaphragm fitting $0 Not covered
• Intrauterine device (IUD) $0 Not covered
• Insertion and/or removal of intrauterine device
(IUD) $0 Not covered
• Implantable contraceptive $0 Not covered
• Tubal ligation $0 Not covered
• Vasectomy 20% Not covered
Podiatric services $20/visit 50%
3
Benefits6 Your payment
When using a
Participating
Provider3
CYD2
applies
When using a
Non-Participating
Provider4
CYD2
applies
Medical nutrition therapy, not related to diabetes 20% 50%
Pregnancy and maternity care
Physician office visits: prenatal and postnatal 20% 50%
Physician services for pregnancy termination 20% Not covered
Emergency Services
Emergency room services $100/visit plus 20% $100/visit plus 20%
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 20% 20%
Urgent care center services $20/visit 50%
Ambulance services 20% 20%
This payment is for emergency or authorized transport.
Outpatient Facility services
Ambulatory Surgery Center 10%
50%
Subject to a
Benefit maximum
of $350/day
Outpatient Department of a Hospital: surgery 20%
50%
Subject to a
Benefit maximum
of $350/day
Outpatient Department of a Hospital: treatment of
illness or injury, radiation therapy, chemotherapy,
and necessary supplies
20%
50%
Subject to a
Benefit maximum
of $350/day
Inpatient facility services
Hospital services and stay 20%
50%
Subject to a
Benefit maximum
of $600/day
4
Benefits6 Your payment
When using a
Participating
Provider3
CYD2
applies
When using a
Non-Participating
Provider4
CYD2
applies
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 20% Not covered
• Physician inpatient services 20% Not covered
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 20% Not covered
Outpatient Facility services 20% Not covered
Physician services 20% Not covered
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 50%
• Outpatient Department of a Hospital $25/visit plus 20%
50%
Subject to a
Benefit maximum
of $350/day
Basic imaging services
Includes plain film X-rays, ultrasounds, and
diagnostic mammography.
• Outpatient radiology center $0 50%
5
Benefits6 Your payment
When using a
Participating
Provider3
CYD2
applies
When using a
Non-Participating
Provider4
CYD2
applies
• Outpatient Department of a Hospital $25/visit plus 20%
50%
Subject to a
Benefit maximum
of $350/day
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 50%
• Outpatient Department of a Hospital $25/visit plus 20%
50%
Subject to a
Benefit maximum
of $350/day
Advanced imaging services
Includes diagnostic radiological and nuclear
imaging such as CT scans, MRIs, MRAs, and PET
scans.
• Outpatient radiology center 20%
50%
Subject to a
Benefit maximum
of $800/day
• Outpatient Department of a Hospital $100/visit plus 20%
50%
Subject to a
Benefit maximum
of $800/day
Rehabilitative and Habilitative Services
Includes physical therapy, occupational therapy, and
respiratory therapy.
Office location 20% 50%
Outpatient Department of a Hospital 20%
50%
Subject to a
Benefit maximum
of $350/day
Speech Therapy services
Office location 20% 50%
Outpatient Department of a Hospital 20%
50%
Subject to a
Benefit maximum
of $350/day
6
Benefits6 Your payment
When using a
Participating
Provider3
CYD2
applies
When using a
Non-Participating
Provider4
CYD2
applies
Durable medical equipment (DME)
DME 20% Not covered
Breast pump $0 Not covered
Orthotic equipment and devices 20% 50%
Prosthetic equipment and devices 20% 50%
Home health care services 20% Not covered
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 20% Not covered
Includes home infusion drugs, medical supplies,
and visits by a nurse.
Hemophilia home infusion services 20% Not covered
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 20% 20%
Hospital-based SNF 20%
50%
Subject to a
Benefit maximum
of $600/day
Hospice program services
Pre-Hospice consultation 20% Not covered
Routine home care 20% Not covered
24-hour continuous home care 20% Not covered
Short-term inpatient care for pain and symptom
management 20% Not covered
Inpatient respite care 20% Not covered
7
Benefits6 Your payment
When using a
Participating
Provider3
CYD2
applies
When using a
Non-Participating
Provider4
CYD2
applies
Other services and supplies
Diabetes care services
• Devices, equipment, and supplies 20% 50%
• Self-management training $20/visit 50%
• Medical nutrition therapy $20/visit 50%
Dialysis services 20%
50%
Subject to a
Benefit maximum
of $300/day
PKU product formulas and special food products 20% Not covered
Allergy serum billed separately from an office visit 20% 50%
Mental Health and Substance Use Disorder Benefits Your payment
When using a Participating Provider3
CYD2 applies
When using a Non-Participating Provider4
CYD2 applies
Outpatient services
Office visit, including Physician office visit $20/visit 50%
Intensive outpatient care $0 50%
Behavioral Health Treatment in an office setting $0 50%
Behavioral Health Treatment in home or other non-
institutional setting $0 50%
Office-based opioid treatment $0 50%
Partial Hospitalization Program $0
50%
Subject to a
Benefit maximum
of $350/day
Psychological Testing $0 50%
Inpatient services
Physician inpatient services 20% 50%
Hospital services 20%
50%
Subject to a
Benefit maximum
of $600/day
Residential Care 20%
50%
Subject to a
Benefit maximum
of $600/day
8
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.
These Covered Services do not have a check mark () next to them in the “CYD applies” column in the Benefits chart
above.
This Plan has a combined Participating Provider and Non-Participating Provider Calendar Year Deductible.
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.
4 Using Non-Participating Providers:
Non-Participating Providers do not have a contract to provide health care services to Members. When you receive
Covered Services from a Non-Participating Provider, you are responsible for:
• the Copayment or Coinsurance (once any Calendar Year Deductible has been met), and
9
Notes
• any charges above the Allowable Amount.
“Allowable Amount” is defined in the Benefit Booklet. In addition:
• Coinsurance is calculated from the Allowable Amount, which is subject to any stated Benefit maximum.
• Charges above the Allowable Amount do not count towards the Deductible or Out-of-Pocket Maximum, and
are your responsibility for payment to the provider. This out-of-pocket expense can be significant.
5 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 and charges above the Allowable Amount.
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.
This Plan has a combined Participating Provider and Non-Participating Provider OOPM.
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.
6 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.
7 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.
lg082225