Blue Shield Gold 80 PPO - Blue Shield Of California

Member Copayment 2BenefitMental Health, Behavioral Health, and Substance Use DisorderBenefits 10Services by MHSAParticipatingProvidersServices by MHSANon-ParticipatingProviders 9Inpatient Hospital services20%Inpatient Professional (Physician) servicesResidential care20%20%50% of up to 2,000per day 1150%50% of up to 2,000per dayAll Services provided through Blue Shield’s Mental Health ServiceAdministrator (MHSA).Mental Health and Behavioral Health – Inpatient ServicesMental Health and Behavioral Health – Routine OutpatientServicesProfessional (Physician) office visits 35 per visit50%Behavioral Health Treatment in home or other non-institutional settingBehavioral Health Treatment in an office-settingElectroconvulsive Therapy (ECT) 13Intensive Outpatient Program 13Partial Hospitalization Program 1220%20%20%20%20% per episodePost discharge ancillary carePsychological testing to determine mental health diagnosis (outpatientdiagnostic testing)Note: For diagnostic laboratory services, see the “Outpatient diagnosticlaboratory services, including Papanicolaou test” section of thisSummary of Benefits. For diagnostic X-ray and imaging services, seethe “Outpatient diagnostic X-ray and imaging services, includingmammography” section of this Summary of Benefits.Transcranial magnetic stimulation20%20%50%50%50%50%50% per episode ofup to 500 per day50%50% of up to 500per dayMental Health and Behavioral Health – Non-Routine OutpatientServices20%50%Inpatient Hospital services20%Inpatient Professional (Physician) services – Substance Use DisorderResidential care20%20%50% of up to 2,000per day 1150%50% of up to 2,000per daySubstance Use Disorder Inpatient ServicesSubstance Use Disorder Outpatient ServicesIntensive Outpatient Program 13Other outpatient services, including office-based opioid treatmentPartial Hospitalization Program 12Post discharge ancillary careProfessional (Physician) office visits20%20%20% per episode20% 35 per visitPage 750%50%50% per episode ofup to 500 per day50%50%

Member Copayment 2BenefitServices byPreferred,Participating, andOther Providers 3Services by NonPreferred and NonParticipatingProviders 4 35 per visit20%50%50%Orthotics BenefitsOffice visitsOrthotic equipment and devicesMember Copayment 2BenefitOutpatient Prescription Drug (Pharmacy) Benefits 14, 15, 16, u pay nothing 15 per prescription 50 per prescription 70 per prescription20% of up to 250per prescriptionNot coveredNot coveredNot coveredNot coveredNot coveredYou pay nothing 45 per prescription 150 per prescription 210 per prescription20% of up to 750per prescriptionNot coveredNot coveredNot coveredNot coveredNot covered20% of up to 250per prescriptionNot covered20% up to 200maximum per 30-daysupplyNot coveredRetail Pharmacy (up to 30-day supply)Contraceptive Drugs and Devices 16Tier 1 DrugsTier 2 DrugsTier 3 DrugsTier 4 Drugs (excluding Specialty Drugs)Mail Service Pharmacy (up to 90-day supply)Contraceptive Drugs and Devices 16Tier 1 DrugsTier 2 DrugsTier 3 DrugsTier 4 Drugs (excluding Specialty Drugs)Network Specialty Pharmacy18, 19Tier 4 DrugsOral Anticancer MedicationsPage 8

Member Copayment 2BenefitServices byPreferred,Participating, andOther Providers 3Services by NonPreferred and NonParticipatingProviders 4 35 per visit50% 35 per visit50% of up to 500per day50%Outpatient X-Ray, Imaging, Pathology, and Laboratory BenefitsNote: Benefits are for diagnostic, non-preventive health services and fordiagnostic radiological procedures, such as CT scans, MRIs, MRAs andPET scans, etc. For Benefits for Preventive Health Services, see the“Preventive Health Benefits” section of this Summary of Benefits.Diagnostic laboratory services, including Papanicolaou test, from anOutpatient Laboratory CenterNote: Participating Laboratory Centers may not be available in allareas. Laboratory services may also be obtained from a Hospital orfrom a laboratory center that is affiliated with a Hospital.Diagnostic laboratory services, including Papanicolaou test, from anoutpatient department of a HospitalDiagnostic X-ray and imaging services, including mammography,from an Outpatient Radiology CenterNote: Participating Radiology Centers may not be available in all areas.Radiology services may also be obtained from a Hospital or from aradiology center that is affiliated with a Hospital.Diagnostic X-ray and imaging services, including mammography,from an outpatient department of a HospitalOutpatient diagnostic testing – OtherTesting in an office location to diagnose illness or injury such asvestibular function tests, EKG, ECG, cardiac monitoring, non-invasivevascular studies, sleep medicine testing, muscle and range of motiontest, EEG and EMG.Outpatient diagnostic testing – OtherTesting in an outpatient department of a Hospital to diagnose illness orinjury, such as vestibular function tests, EKG, ECG, cardiac monitoring,non-invasive vascular studies, sleep medicine testing, muscle and rangeof motion test, EEG and EMG.Radiological and Nuclear Imaging servicesServices provided in the outpatient department of a Hospital. Priorauthorization is required. Please see the Benefits Management Programsection in the Evidence of Coverage for specific information. 50 per visit 50 per visit20%50% of up to 500per day50%20%50% of up to 500per day20%50% of up to 500per day20%20% 55 per visit50%PKU Related Formulas and Special Food Products BenefitsPKUPodiatric BenefitsPodiatric ServicesPage 9

Member Copayment 2BenefitServices byPreferred,Participating, andOther Providers 3Services by NonPreferred and NonParticipatingProviders 420%20%You pay nothingYou pay nothing50% of up to 2,000per day50%50%50% 35 per visit20%50%50%You pay nothingNot covered20%50% 35 per visit20% 55 per visit 35 per visit50%50%50%50% 60 per visit 55 per visit50%50% 35 per visit20%50%50%Pregnancy and Maternity Care BenefitsNote: Routine newborn circumcision is only covered as described inthe Covered Services section of the Evidence of Coverage. Serviceswill be covered as any other surgery and paid as noted in this Summaryof Benefits.Inpatient Hospital services for normal delivery, Cesarean section, andcomplications of pregnancyDelivery and all inpatient physician servicesPrenatal and preconception Physician office visit: initial visitPrenatal and preconception Physician office visit: subsequent visits,including prenatal diagnosis of genetic disorders of the fetus by meansof diagnostic procedures in cases of high-risk pregnancyPostnatal Physician office visitsAbortion servicesCoinsurance/Copayment shown is for physician services in the officeor outpatient facility. If the procedure is performed in a facility setting(Hospital or Outpatient Facility), an additional facilityCoinsurance/Copayment may apply.Preventive Health Benefits 20Preventive Health ServicesSee Preventive Health Services, in the Principal Benefits andCoverages (Covered Services) section of the Evidence of Coverage,for more information.Professional BenefitsInpatient Physician ServicesFor bariatric surgery services, see the “Bariatric Surgery” section inthis Summary of Benefits.Other practitioner office visitOutpatient Physician services, other than an office settingPhysician home visitsPrimary Care Physician office visitsNote: For other services with the office visit, you may incur anadditional Copayment as listed for that service within this Summary ofBenefits.Physician services in an Urgent Care CenterSpecialist Physician office visitsProsthetic Appliance BenefitsOffice visitsProsthetic equipment and devicesPage 10

Member Copayment 2BenefitServices byPreferred,Participating, andOther Providers 3Services by NonPreferred and NonParticipatingProviders 4For Physician services for these Benefits, see the “ProfessionalBenefits” section of this Summary of Benefits.Ambulatory Surgery Center outpatient surgery facility services20%Inpatient Hospital services20%Outpatient department of a Hospital20%50% of up to 300per day50% of up to 2,000per day50% of up to 500per dayReconstructive Surgery BenefitsRehabilitation and Habilitation Services Benefits (Physical,Occupational and Respiratory Therapy)Rehabilitation Services in an office location or outpatient departmentof a Hospital.Note: Rehabilitation and Habilitation Services may also be obtainedfrom a Hospital or SNF as part of an inpatient stay in one of thosefacilities. In this instance, Covered Services will be paid at theParticipating or Non-Participating level as specified under theapplicable section, Hospital Benefits (Facility Services) or SkilledNursing Facility Benefits, of this Summary of Benefits.Office locationOutpatient department of a Hospital 35 per visit 35 per visit50%50% of up to 500per day20%20% 35 per visit 35 per visit50%50% of up to 500per daySkilled Nursing Facility (SNF) BenefitsSkilled nursing services by a free-standing Skilled Nursing FacilityUp to a maximum of 100 days per Member, per Benefit Period, exceptwhen received through a Hospice Program provided by a ParticipatingHospice Agency. This day maximum is a combined Benefit maximumfor all skilled nursing services whether rendered in a Hospital or a freestanding SNF.If your benefit plan has a Calendar Year Medical Deductible, thenumber of days counts towards the day maximum even if the CalendarYear Medical Deductible has not been met.Speech Therapy BenefitsSpeech Therapy services in an office location or outpatient departmentof a Hospital.Note: Speech Therapy services may also be obtained from a Hospital orSNF as part of an inpatient stay in one of those facilities. In this instance,Covered Services will be paid at the Participating or Non-Participatinglevel as specified under the applicable section, Hospital Benefits(Facility Services) or Skilled Nursing Facility Benefits, of this Summaryof Benefits.Office locationOutpatient department of a HospitalPage 11

Member Copayment 2BenefitServices byPreferred,Participating, andOther Providers 3Services by NonPreferred and NonParticipatingProviders 4Organ Transplant Benefits for transplant of tissue or kidney.Hospital services20%Professional (Physician) services20%50% of up to 2,000per day50%20%20%Not coveredNot coveredTransplant Benefits – Tissue and KidneyTransplant Benefits – SpecialBlue Shield requires prior authorization for all Special TransplantServices, and all services must be provided at a Special TransplantFacility designated by Blue Shield.See the Transplant Benefits – Special Transplants section of thePrincipal Benefits (Covered Services) section in the Evidence ofCoverage for important information on this Benefit.Facility services in a Special Transplant FacilityProfessional (Physician) servicesPage 12

Member Copayment ider 4, 22You pay nothingUp to 30You pay nothingUp to 30You pay nothingYou pay nothingYou pay nothingYou pay nothingUp to 25Up to 35Up to 45Up to 45You pay nothing 55 95 35 25 25 30 45Not coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredNot coveredYou pay nothingUp to 150Up to 40Up to 40Pediatric Vision Benefits 25Pediatric vision benefits are available for members through the end ofthe month in which the member turns 19.All Services provided through Blue Shield’s Vision Plan Administrator(VPA).Comprehensive examination 21One comprehensive eye examination per Calendar Year.Includes dilation, if professionally indicated.OphthalmologicNew Patient (S0620)Established Patient (S0621)OptometricNew Patient (92002/92004)Established Patient (92012/92014)Eyewear/materialsOne pair of eyeglasses (frames and lenses) or one pair of contact lensesper Calendar Year (unless otherwise noted) as follows:LensesLenses include choice of glass or plastic lenses, all lens powers(single vision, bifocal, trifocal, lenticular), fashion or gradient tint,scratch coating, oversized, and glass-grey #3 prescription sunglass.Polycarbonate lenses are covered in full for eligible Members.Single Vision (V2100-V2199)Lined Bifocal (V2200-V2299)Lined Trifocal (V2300-V2399)Lenticular (V2121, V2221, V2321)Optional Lenses and TreatmentsUltraviolet Protective Coating (standard only)Standard Progressive LensesPremium Progressive LensesAnti-Reflective Lens Coating (standard only)Photochromic- Glass LensesPhotochromic- Plastic LensesHi Index LensesPolarized LensesFrames 23Collection framesNon-Collection framesPage 13

Member Copayment ider 4, 22You pay nothingYou pay nothingYou pay nothingUp to 225Up to 75Up to 75You pay nothingUp to 75You pay nothingUp to 7535%Not coveredYou pay nothingNot coveredContact Lenses 24Non-Elective (Medically Necessary) – Hard or softElective (Cosmetic/Convenience) – Standard hard (V2500, V2510)Elective (Cosmetic/Convenience) – Standard soft (V2520)One pair per month, up to 6 months, per Calendar Year.Elective (Cosmetic/Convenience) – Non-standard hard (V2501V2503, V2511-V2513, V2530-V2531)Elective (Cosmetic/Convenience) – Non-standard soft (V2521V2523)One pair per month, up to 3 months, per Calendar Year.Supplemental Low-Vision Testing and Equipment 26Diabetes Management ReferralMember Copayment 3BenefitServices byPreferred andParticipatingDentistServices by NonPreferred and NonParticipating DentistYou pay 0%50%30%32Pediatric Dental Benefits 27Pediatric dental benefits are available for Members through the end ofthe month in which the Member turns 19.Diagnostic and Preventive Care Services28Restorative Services 29Oral surgery 29, 30Endodontics 29, 30Periodontics 29, 30Crowns and Fixed Bridges 29, 30Removable Prosthetics 29, 30Orthodontics 29, 30, 31Other BenefitsPage 14

Summary of BenefitsEndnotes:12345For an individual on a family coverage plan, a Member can receive 100% benefits for covered services once theindividual out-of-pocket maximum is met in a calendar year and before the family out-of-pocket maximum is met.Copayments or Coinsurance for Covered Services accrue to the Calendar Year Out-of-Pocket Maximum,except Copayments or Coinsurance for Covered Services listed in the following sections of this Summary ofBenefits: Charges in excess of specified benefit maximumsBariatric surgery: covered travel expenses for bariatric surgeryDialysis center benefits: dialysis services from a Non-Participating ProviderNote: Copayments, Coinsurance and charges for services not accruing to the Calendar Year Out-of-PocketMaximum continue to be the Member's responsibility after the Calendar Year Out-of-Pocket Maximum is reached.Any Coinsurance is calculated based on the Allowable Amount unless otherwise specified.For Covered Services from Other Providers, you are responsible for any Copayment/Coinsurance and all chargesabove the Allowable Amount.For Covered Services by Non-Preferred and Non-Participating Providers you are responsible for all charges abovethe Allowable Amount. Covered Services by Non-Preferred and Non-Participating Providers that are priorauthorized, as Preferred or Participating will be covered as a Preferred and Participating Provider Benefit.Professional (Physician) office visit copayment/coinsurance may also apply.6Family Planning Services are only covered when provided by Participating or Preferred Providers.7Services from a Non-Participating Home Health Care/Home Infusion Agency are not covered unless priorauthorized. When services are authorized, the Member’s Copayment or Coinsurance will be calculated at theParticipating Provider level, based upon the agreed upon rate between Blue Shield and the agency.Services from a Non-Participating Hospice Agency are not covered unless prior authorized. When services areauthorized, the Member’s Copayment or Coinsurance will be calculated at the Participating Provider level, basedupon the agreed upon rate between Blue Shield and the agency.For Covered Services from Non-Participating MHSA Providers, you are responsible for a Copayment/Coinsuranceand all charges above the Allowable Amount.Prior authorization from the MHSA is required for all non-Emergency or non-Urgent Inpatient Services, NonRoutine Outpatient Mental and Behavioral Health, and Outpatient Substance Use Disorder Services. No priorauthorization is required for Routine Outpatient Mental and Behavioral Health, and Outpatient Substance UseDisorder Services – Professional (Physician) Office Visit.For Emergency Services from a MHSA Non-Participating Hospital, the Member’s Copayment or Coinsurance willbe the MHSA Participating level, based on Allowable Amount.For Non-Routine Outpatient Mental and Behavioral Health, and Outpatient Substance Use Disorder Services Partial Hospitalization Program services, an episode of care is the date from which the patient is admitted to thePartial Hospitalization Program and ends on the date the patient is discharged or leaves the Partial HospitalizationProgram. Any services received between these two dates would constitute an episode of care. If the patient needsto be readmitted at a later date, then this would constitute another episode of care.The Member’s Copayment or Coinsurance includes both outpatient facility and Professional Services.89101112131415This benefit plan’s prescription drug coverage is on average equivalent to or better than the standard benefit set bythe federal government for Medicare Part D (also called creditable coverage). Because this benefit plan’sprescription drug coverage is creditable, you do not have to enroll in Medicare Part D while you maintain thiscoverage; however, you should be aware that if you have a subsequent break in this coverage of 63 days or morebefore enrolling in Medicare Part D you could be subject to payment of higher Medicare Part D premiums.If the Member or Physician request a Drug when a Generic Drug equivalent is available, the Member is responsiblefor paying the difference between the Participating Pharmacy’s contracted rate for the Brand Drug and its GenericDrug equivalent, as well as the applicable Generic Drug Copayment or Coinsurance. The difference in cost that theMember must pay is not applied to the Calendar Year Deductible and is not included in the Calendar Year Out-ofPocket maximum responsibility calculation.Page 15

161718192021222324252627282930There is no Copayment or Coinsurance for contraceptive drugs and devices, however, if a Brand contraceptive drugis selected when a Generic Drug equivalent is available, the Member is responsible for the difference between thecost to Blue Shield for the Brand contraceptive drug and its Generic Drug equivalent. If the Brand contraceptivedrug is Medically Necessary, it may be covered without a Copayment or Coinsurance with prior authorization. Thedifference

Blue Shield Gold 80 PPO Plan Summary of Benefits The Summary of Benefits is provided with, and is incorporated as part of, the Evidence of Coverage. It sets forth the Member’s share-of-costs for Covered Services under the benefit plan. Please read both documents carefullyFile Size: 860KBPage Count: 107Explore furtherIndividual and Family Plan PPO Plan Summary of Benefits .www.blueshieldca.com2021 Summary of Benefits - Producer Connectionwww.blueshieldca.comHow are bronze, silver and gold plans different? bcbsm.comwww.bcbsm.comMember Services - Blue Cross Blue Shield Associationwww.bcbs.comFind a Doctor - Blue Cross Blue Shield Associationwww.bcbs.comRecommended to you b